Presence of urinary symptoms in bacteremic urinary tract infection: a retrospective cohort study of Escherichia coli bacteremia

Comparison of oral versus intravenous antimicrobial therapy for patients who were diagnosed with bloodstream infections due to Gram-negative bacilli after discharge from the emergency department: A retrospective analysis

INTRODUCTION

Infections caused by Gram-negative bacilli (GNB) in the emergency department (ED) are common, and the blood cultures taken at the visit can turn positive often after the discharge. However, the differences in the clinical outcomes depending on the subsequent decision-making, either to giving the patients intravenous or oral antibiotics remain unknown.

METHODS

A single-center retrospective observational study was conducted for the outcome of the patients whose blood cultures at the visit turned positive and detected GNB. The primary outcomes were 30- and 90-day all-cause mortality from the first positive blood cultures, comparing intravenous treatment (IVT) and oral treatment (OT). The propensity score analysis was used to adjust potential confounders.

RESULTS

A total of 283 patients with GNB bloodstream infections (BSIs) diagnosed after ED discharge. No death occurred in either group within 30 days, with the average treatment effect (ATE) of OT being <0.001 (p = 0.45) after inverse probability weighting (IPW). At 90 days, mortality was 2.5 % for the OT group and 0 % for the IVT group (ATE 0.051; 96%CI 0.013-0.098; p = 0.001).

CONCLUSION

All of patients treated with oral antibiotics were alive at 30 days, but had a higher 90-day mortality compared to those given intravenous agents. The results were consistent after adjusting the potential confounders by using IPW. Given the overall low mortality in both groups after 90 days, even though oral antibiotic therapy was associated with higher mortality statistically, one might consider this as an option especially when the patient's preference was compelling.

Diagnosing probable urinary tract infections in nursing home residents without indwelling catheters: a narrative review

BACKGROUND

Overdiagnosis of urinary tract infections (UTIs) is one of the most common reasons for the unnecessary use of antibiotics in nursing homes, increasing the risk of missing serious conditions. Various decision tools and algorithms aim to aid in UTI diagnosis and the initiation of antibiotic therapy for residents. However, due to the lack of a clear reference standard, these tools vary widely and can be complex, with some requiring urine testing. As part of the European-funded IMAGINE project, aimed at improving antibiotic use for UTIs in nursing home residents, we have reviewed the recommendations.

OBJECTIVES

This review provides a comprehensive summary of the more relevant tools and algorithms aimed at identifying true UTIs among residents living in nursing homes and discusses the challenges in using these algorithms based on updated research.

SOURCES

The discussion is based on a relevant medical literature search and synthesis of the findings and published tools to provide an overview of the current state of improving the diagnosis of UTIs in nursing homes.

CONTENT

The following topics are covered: prevalence of asymptomatic bacteriuria, diagnostic challenges, clinical criteria, urinary testing, and algorithms to be implemented in nursing home facilities.

IMPLICATIONS

Diagnosing UTIs in residents is challenging due to the high prevalence of asymptomatic bacteriuria and nonspecific urinary tract signs and symptoms among those with suspected UTIs. The fear of missing a UTI and the perceived antibiotic demands from residents and relatives might lead to overdiagnosis of this common condition. Despite their widespread use, urine dipsticks should not be recommended for geriatric patients. Patients who do not meet the minimum diagnostic criteria for UTIs should be evaluated for alternative conditions. Adherence to a simple algorithm can prevent unnecessary antibiotic courses without compromising resident safety.

Treatment Patterns and Adherence to Guidelines for Uncomplicated Urinary Tract Infection in Germany: A Retrospective Cohort Study

INTRODUCTION

Understanding antibiotic prescribing for uncomplicated urinary tract infection (uUTI) could help to optimize management. However, data on uUTI treatment patterns in the European Union are scarce. We used real-world data to evaluate adherence to antibiotic prescribing guidelines for femalepatients with uUTI in Germany.

METHODS

This retrospective cohort study used anonymized German statutory health insurance claims data from the Wissenschaftliches Institut für Gesundheitsökonomie und Gesundheitssystemforschung from January 2013 to December 2019. Patients were female, aged ≥ 12 years, with an index uUTI diagnosis. Patient characteristics and treating physician specialties were examined overall and in sub-cohorts for recommended/non-recommended treatment (based on initial therapy adherence to German uUTI treatment guidelines) and optimal/sub-optimal outcome (based on a prescription of different antibiotics or a urinary tract infection-related episode).

RESULTS

Overall, 144,645 uUTI cases in 124,971 patients were analyzed; 51,230 (35.4%) and 93,415 (64.6%) cases were assigned to the recommended/non-recommended treatment sub-cohorts, respectively. Clinically meaningful differences in age and comorbidities were observed between these sub-cohorts. Most cases had an optimal outcome (n = 122,823; 84.9%); of these, a higher proportion received antibiotics that were recommended but not as first-choice versus first-choice therapies as their initial treatment (58.6% vs. 35.3%). In the sub-optimal outcome cohort, 49.1% received antibiotics that were recommended but not as first-choice and 41.1% received first-choice therapies as their initial treatment. Most uUTIs were treated by general practitioners (GPs; 82.3%), followed by gynecologists (13.3%), and urologists (6.8%). Notably, 64.5% of initial therapy prescriptions filled by gynecologists and 32.1% by GPs were first-choice antibiotics.

CONCLUSION

A high proportion of prescribed treatments for the initial uUTI episode were not recommended by German uUTI guidelines as first-choice antibiotics. Prescribing adherence varied by physician specialty; specialists showed greater adherence to treatment guidelines versus GPs. This study provides a novel and multi-dimensional picture of uUTI treatment in Germany.

Novel evidence on sepsis-inducing pathogens: from laboratory to bedside

Sepsis is a life-threatening condition and a significant cause of preventable morbidity and mortality globally. Among the leading causative agents of sepsis are bacterial pathogens Escherichia coli, Klebsiella pneumoniae, Staphylococcus aureus, Pseudomonas aeruginosa, and Streptococcus pyogenes, along with fungal pathogens of the Candida species. Here, we focus on evidence from human studies but also include in vitro and in vivo cellular and molecular evidence, exploring how bacterial and fungal pathogens are associated with bloodstream infection and sepsis. This review presents a narrative update on pathogen epidemiology, virulence factors, host factors of susceptibility, mechanisms of immunomodulation, current therapies, antibiotic resistance, and opportunities for diagnosis, prognosis, and therapeutics, through the perspective of bloodstream infection and sepsis. A list of curated novel host and pathogen factors, diagnostic and prognostic markers, and potential therapeutical targets to tackle sepsis from the research laboratory is presented. Further, we discuss the complex nature of sepsis depending on the sepsis-inducing pathogen and host susceptibility, the more common strains associated with severe pathology and how these aspects may impact in the management of the clinical presentation of sepsis.

Epidemiology, Clinical Features, and Antimicrobial Resistance of Invasive Escherichia Coli Disease in Patients Admitted in Tertiary Care Hospitals

Background

Invasive Escherichia coli disease (IED), including bloodstream infection, sepsis, and septic shock, can lead to high hospitalization and mortality rates. This multinational study describes the clinical profile of patients with IED in tertiary care hospitals.

Methods

We applied clinical criteria of systemic inflammatory response syndrome (SIRS), sepsis, or septic shock to patients hospitalized with culture-confirmed E coli from urine or a presumed sterile site. We assessed a proposed clinical case definition against physician diagnoses.

Results

Most patients with IED (N = 902) were adults aged ≥60 years (76.5%); 51.9%, 25.1%, and 23.0% of cases were community-acquired (CA), hospital-acquired (HA), and healthcare-associated (HCA), respectively. The urinary tract was the most common source of infection (52.3%). Systemic inflammatory response syndrome, sepsis, and septic shock were identified in 77.4%, 65.3%, and 14.1% of patients, respectively. Patients >60 years were more likely to exhibit organ dysfunction than those ≤60 years; this trend was not observed for SIRS. The case-fatality rate (CFR) was 20.0% (60-75 years, 21.5%; ≥75 years, 22.2%), with an increase across IED acquisition settings (HA, 28.3%; HCA, 21.7%; CA, 15.2%). Noticeably, 77.8% of patients initiated antibiotic use on the day of culture sample collection. A total of 65.6% and 40.8% of E coli isolates were resistant to ≥1 agent in ≥1 or ≥2 drug class(es). A 96.1% agreement was seen between the proposed clinical case definition and physician's diagnoses of IED.

Conclusions

This study contributes valuable, real-world data about IED severity. An accepted case definition could promote timely and accurate diagnosis of IED and inform the development of novel preventative strategies.

Genome analysis of a new Escherichia phage vB_EcoM_C2-3 with lytic activity against multidrug-resistant Escherichia coli

In this study, we present the complete, annotated genome of a new member of the Tequatrovirus (T4-like) genus, Escherichia phage vB_EcoM_C2-3. This phage has an isometric head (92 nm in diameter) and a contractile tail (114 nm in length). Its genome consists of a linear, double-stranded DNA of 167,069bp with an average G+C content of 35.3%. There are 267 predicted genes, of which 125 encode functional proteins, including those for DNA replication, transcription and packaging, phage morphogenesis and cell lysis. Neither genes involved in the regulation of lysogeny nor antibiotic resistance genes were identified. Based on our results, its genomic features provide valuable insights into the use of a potential biocontrol agent, as Escherichia phage vB_EcoM_C2-3 exhibited lytic activity against E. coli, including multidrug-resistant strains.

Atypical Presentation of Bacteremic Urinary Tract Infection in Older Patients: Frequency and Prognostic Impact

In older patients, urinary tract infection (UTI) often has an atypical clinical presentation, making its diagnosis difficult. We aimed to describe the clinical presentation in older inpatients with UTI-related bacteremia and to determine the prognostic impact of atypical presentation. This cohort study included all consecutive patients older than 75 years hospitalized in a university hospital in 2019 with a UTI-related gram-negative bacillus (GNB) bacteremia, defined by blood and urine cultures positive for the same GNB, and followed up for 90 days. Patients with typical symptoms of UTI were compared to patients with atypical forms. Among 3865 inpatients over 75 with GNB-positive urine culture over the inclusion period, 105 patients (2.7%) with bacteremic UTI were included (mean age 85.3 ± 5.9, 61.9% female). Among them, UTI symptoms were reported in only 38 patients (36.2%) and 44 patients (41.9%) had no fever on initial management. Initial diagnosis of UTI was made in only 58% of patient. Mortality at 90 days was 23.6%. After adjustment for confounders, hyperthermia (HR = 0.37; IC95 (0.14–0.97)) and early UTI diagnosis (HR = 0.35; IC95 (0.13–0.94)) were associated with lower mortality, while UTI symptoms were not associated with prognosis. In conclusion, only one third of older patients with UTI developing bacteremia had UTI symptoms. However, early UTI diagnosis was associated with better survival.