Inadequate empirical antimicrobial treatment in older people with bacteremic urinary tract infection who reside in nursing homes: A multicenter prospective observational study

How do residential aged care antibiograms compare with other local resistance data?

BACKGROUND

Antibiograms can optimize empirical antibiotic prescribing; however, they are not readily available for residential aged care facilities (RACFs) in Queensland, Australia. This study aimed to determine whether alternatively available data can be used to approximate resistance patterns for RACFs.

METHODS

Annual RACF-specific antibiograms were compared with local hospital antibiograms accessed through pathology providers. Additionally, composite antibiograms, of geographically united RACF data, were compared with regional hospital and private pathology RACF antibiograms. Antibiotic susceptibility rates for commonly observed bacteria (Escherichia coli, Klebsiella pneumonia, Enterococcus faecalis, Pseudomonas aeruginosa, and Staphylococcus aureus) were compared among different antibiograms using Fisher exact test, with a P value ≤ 0.05 indicating the statistically significant difference. The concordance among the antibiograms was described by percentage similarity overall and for a subset of clinically relevant pathogen-antibiotic pairs.

RESULTS

Composite RACF antibiogram was highly concordant (83%-100% similarity) to private pathology RACF data when compared for clinically relevant pathogen-antibiotic pairs. Mixed results were found when individual RACF-specific antibiograms were compared with local hospital all-ages and ≥ 65 years data (50%-100% and 67%-100% similarity, respectively).

CONCLUSIONS

Private pathology RACF antibiograms can serve as a proxy indicator of resistance patterns for RACFs. Mixed findings were noted for comparisons with hospital data.

Antibiogram development for Australian residential aged care facilities

OBJECTIVE

Knowledge of local antibiotic resistance data, provided by antibiograms (a cumulative summary of in vitro-antimicrobial-susceptibility-test results), can aid prescribing of appropriate empirical antibiotics. This study aimed to explore the feasibility of antibiogram development for residential aged care facilities (RACFs).

DESIGN

Retrospective observational study of culture and sensitivity data.

SETTING

Nine RACFs in Queensland, Australia.

METHOD

Available antimicrobial susceptibility results were collected retrospectively for all residents of recruited RACFs from January 1, 2020, to December 31, 2022. Data were managed and analyzed with WHONET software®, and antibiograms were developed in accordance with the CLSI-M39 guidelines. Antibiogram data beyond the standard 12-months and pooling of data from geographically similar RACFs were explored as options to improve feasibility and validity of the antibiograms.

RESULTS

The most prevalent bacteria in the RACFs were Escherichia coli and Staphylococcus aureus. Due to the low number of positive cultures (less than 30) for individual RACFs, an annual antibiogram was not feasible. Extending the time-period to three years improved feasibility of antibiograms for E.coli in seven RACFs and S.aureus in five RACFs. Combining the data from closely located RACFs allowed for sufficient urinary and skin swab isolates to produce annual pooled antibiograms for all three years.

CONCLUSION

Use of extended time period antibiograms can provide RACF specific urinary and skin/soft tissue resistance data without the necessity of private pathology provider input. However, pooled syndromic antibiograms can be made available on an annual basis, which may be the preferred option.

Nursing home-associated bloodstream infection: A scoping review

OBJECTIVE

To update a 2005 review of nursing home-associated bloodstream infection (NHABSI) regarding sources, organisms, antibiotic resistance, and outcome.

METHODS

A scoping review of studies of NHABSI identified by searching Google Scholar and Medline with OVID for the period January 1, 2004, to June 30, 2021, was conducted.

RESULTS

Overall, 6 studies of NHABSI were identified. Only 1 study was conducted with residents in North American facilities whereas in the 2005 review all studies were conducted in North America. Escherichia coli was the most common blood isolate, the urinary tract was the most common source of NHABSI; and the case-fatality rates ranged from 21% to 28%. These findings were comparable to those in the 2005 review. However, the proportion of NHABSI episodes due to antibiotic-resistant organisms increased substantially compared to the 2005 review. The most common antibiotic-resistant organisms were extended-spectrum β-lactamase-producing E. coli and Klebsiella spp. The 2 studies that evaluated the relationship between appropriate empiric antibiotic therapy and outcome came to different conclusions.

CONCLUSIONS

The only major difference between the 2 reviews in the epidemiology of NHABSI was the marked increase in antibiotic resistance among blood isolates. Despite the increased antibiotic resistance, the case fatality rates in the current review were comparable to those reported in the 2005 review. However, the impact of appropriate empiric antibiotic therapy on outcome of NHABSI remains unclear.

Sex differences in aged 80 and over hospitalized patients with community-acquired UTI: A prospective observational study

Aim

This study aimed to evaluate clinically significant sex differences that could have an effect on the choice of treatment and outcomes of urinary tract infection (UTI) in aged 80 and over hospitalized patients with community-acquired UTI.

Methods

This was a prospective study of 161 patients aged 80 and over admitted to hospital with community-acquired UTI. Epidemiological, clinical, laboratory and microbiologic variables were compared between both sexes. Multivariate analysis was performed using logistic regression to determine the variables independently associated with sex.

Results

In a population of 91 (56.52%) women and 70 (43.48%) men, aged 80 and over, we found that women were more likely to have cognitive impairment (p = 0.035) and less likely to have chronic obstructive pulmonary disease (COPD) (p = 0.006) and indwelling urinary catheter (p < 0.001) than men. Levels of creatinine were higher in men than in women (p = 0.008). Septic shock at presentation was more frequent in the male group (p = 0.043). Men had a higher rate of polymicrobial infection (p = 0.035) and Pseudomonas aeruginosa infection (p = 0.003). Factors independently associated with sex by multivariate analysis were septic shock, cognitive impairment, COPD and indwelling urinary catheter.

Conclusion

Men aged 80 and over with community-acquired UTI had more septic shock at admission to hospital and higher rates of indwelling urinary catheter, while women had more cognitive impairment. There were no differences in outcomes between sexes.

Clinical impact of multidrug-resistant bacteria in older hospitalized patients with community-acquired urinary tract infection

Introduction

Previous studies have described some risk factors for multidrug-resistant (MDR) bacteria in urinary tract infection (UTI). However, the clinical impact of MDR bacteria on older hospitalized patients with community-acquired UTI has not been broadly analyzed. We conducted a study in older adults with community-acquired UTI in order to identify risk factors for MDR bacteria and to know their clinical impact.

Methods

Cohort prospective observational study of patients of 65 years or older, consecutively admitted to a university hospital, diagnosed with community-acquired UTI. We compared epidemiological and clinical variables and outcomes, from UTI due to MDR and non-MDR bacteria. Independent risk factors for MDR bacteria were analyzed using logistic regression.

Results

348 patients were included, 41.4% of them with UTI due to MDR bacteria. Median age was 81 years. Hospital mortality was 8.6%, with no difference between the MDR and non-MDR bacteria groups. Median length of stay was 5 [4–8] days, with a longer stay in the MDR group (6 [4–8] vs. 5 [4–7] days, p = 0.029). Inadequate empirical antimicrobial therapy (IEAT) was 23.3%, with statistically significant differences between groups (33.3% vs. 16.2%, p < 0.001). Healthcare-associated UTI variables, in particular previous antimicrobial therapy and residence in a nursing home, were found to be independent risk factors for MDR bacteria.

Conclusions

The clinical impact of MDR bacteria was moderate. MDR bacteria cases had higher IEAT and longer hospital stay, although mortality was not higher. Previous antimicrobial therapy and residence in a nursing home were independent risk factors for MDR bacteria.

Impact of inappropriate empirical antibiotic treatment on clinical outcomes of urinary tract infections caused by Escherichia coli: a retrospective cohort study

OBJECTIVES

We aimed to determine the clinical impact of inappropriate empirical antibiotic treatment (IEAT) compared with appropriate empirical antibiotic treatment (AEAT) in hospitalised patients with urinary tract infections (UTIs) caused by Escherichia coli (E. coli).

METHODS

This retrospective cohort study included adult patients with a primary diagnosis of UTI who were treated with empirical antibiotics at a tertiary hospital in southern China over a 2-year period. Clinical data of patients who received IEAT were compared with those of patients receiving AEAT. We used multivariable logistic regression to identify the predictors for receiving IEAT and the risk factors affecting clinical outcomes.

RESULTS

A total of 213 patients were enrolled (median age, 61 years), of whom 103 (48.4%) received IEAT. IEAT was associated with empirical use of fluoroquinolones, male sex and age-adjusted Charlson comorbidity index (aCCI) score >6. Hospital length of stay (LOS) was longer for patients who received IEAT than for those who received AEAT (13.6 ± 8.6 days vs. 10.8 ± 7.9 days; P = 0.008). IEAT was an independent risk factor for longer LOS along with aCCI score ≥2, lung disease and cardiac disease.

CONCLUSION

Empirical use of fluoroquinolones for UTIs should be avoided, especially in male patients with aCCI score >6. Improved empirical antimicrobial therapy may have a beneficial impact in reducing bacterial resistance and healthcare costs by decreasing the LOS. Therefore, interventions to promote in-depth antibiotic stewardship programmes in China are needed.