Relationship between the appropriateness of antibiotic treatment and clinical outcomes/medical costs of patients with community-acquired acute pyelonephritis: a multicenter prospective cohort study

Clinical and microbiological characteristics of female patients with acute pyelonephritis who experienced urinary tract infections within the previous year

BACKGROUND

This study aimed to examine the clinical and microbiological characteristics of female patients with recurrent acute pyelonephritis (APN).

METHODS

A retrospective cohort study was conducted at a tertiary care hospital in South Korea from July 2019 to December 2021. All female patients aged ≥ 19 years who were diagnosed with community-acquired APN on admission were enrolled. The recurrent group included patients with APN who experienced urinary tract infections within the previous year. The clinical characteristics, types of causative organisms, major antibiotic resistance, and molecular characteristics of Escherichia coli strains were compared between the recurrent and non-recurrent groups.

RESULTS

A total of 285 patients with APN were analyzed, including 41 (14.4%) in the recurrent group. Compared to the non-recurrent group, the recurrent group had a higher Charlson Comorbidity Index (1.8 ± 2.1 vs. 1.1 ± 1.5; P = 0.01) and a higher proportion of bladder abnormalities, such as neurogenic bladder (12.2% vs. 2.0%; P = 0.001) and urinary catheterization (12.2% vs. 1.6%; P < 0.001). Escherichia coli was the most common causative organism in both groups. The proportion of Klebsiella pneumoniae (17.1% vs. 4.7%; P = 0.007) and Pseudomonas aeruginosa (5.7% vs. 0.5%; P = 0.014) as a causative organism was higher in the recurrent group. Regarding the microbiological characteristics of Escherichia coli, there were no significant differences in the proportion of antibiotic resistance, phylogenetic groups, resistance genes, and virulence factors between the two groups. Multivariable analysis showed that neurogenic bladder and a history of admission or antibiotic use during 1 year prior to inclusion were significantly associated with recurrent APN.

CONCLUSIONS

The proportion of causative organisms except Escherichia coli was higher in the recurrent group than in the non-recurrent group. Neurogenic bladder and a history of admission or antibiotic use during 1 year prior to inclusion were risk factors for recurrent APN.

Contrast-Enhanced Ultrasound Follow-Up for Acute Pyelonephritis Patients

Contrast-enhanced ultrasound (CEUS) is increasingly used in clinical practice as the first diagnostic method in patients with suspected pyelonephritis rather than abdominal CT with contrast medium, especially in young subjects. We performed a retrospective analysis on patients in for whom a CEUS examination was utilized as a follow-up method after acute pyelonephritis as normal clinical practice. Through evaluating all patients, in terms duration between CEUS examination and normalization (healing) of the renal disease, we found that the mean duration is 25.9 days. Our ultrasound findings did not induce any therapeutic modifications, not even in the cases in which the examination was repeated several times. Therefore, setting up a CEUS follow-up examination after 25 days from the first diagnosis can reduce the number of repeated tests, benefitting patients and the healthcare system in terms of reducing costs.

Appropriateness of antibiotic use for patients with asymptomatic bacteriuria or urinary tract infection with positive urine culture: a retrospective observational multi-centre study in Korea

BACKGROUND

Antibiotic resistance threatens public health worldwide, and inappropriate use of antibiotics is one of the main causes.

AIM

To evaluate qualitative use of antibiotics in asymptomatic bacteriuria (ABU) and urinary tract infection (UTI).

METHODS

Cases of positive urine culture (≥105 colony-forning units/mL) performed in inpatient, outpatient and emergency departments in April 2021 were screened in 26 hospitals in the Republic of Korea. The cases were classified as ABU, lower UTI and upper UTI. The appropriateness of antibiotic use was evaluated retrospectively by infectious disease specialists using quality indicators based on clinical guidelines for ABU and UTI.

RESULTS

This study included a total of 2697 patients with ABU or UTI. The appropriateness of antibiotic use was assessed in 1157 patients with ABU, and in 677 and 863 patients with lower and upper UTI, respectively. Among the 1157 patients with ABU, 251 (22%) were prescribed antibiotics without appropriate indications. In 66 patients with ABU in which antibiotics were prescribed with appropriate indications, the duration was adequate in only 23 (34.8%) patients. The appropriateness of empirical and definite antibiotics was noted in 527 (77.8%) and 353 (68.0%) patients with lower UTI, and 745 (86.3%) and 583 (78.2%) patients with upper UTI, respectively. The duration of antibiotics was adequate in 321 (61.8%) patients with lower UTI and 576 (78.7%) patients with upper UTI.

CONCLUSIONS

This nationwide qualitative assessment of antibiotic use in ABU and UTI revealed that antibiotics were often prescribed inappropriately, and the duration of antibiotics was unnecessarily prolonged.

Evaluation of the Use of Antimicrobial Therapy for Treating Diabetic Foot Infections in an Indonesia Referral Hospital: A Retrospective Cohort Study

BACKGROUND

Diabetic foot infection (DFI) is a common complication of hyperglycemia and is related to prolongation of hospitalization, mortality, high hospitalization costs and decreased quality of life. Antibiotic therapy is one of the most critical factors in the eradication of infection. This study aims to determine the appropriateness of antibiotic use based on the local and international clinical guidelines and its short-term effect on patients' clinical improvement.

MATERIALS AND METHODS

This retrospective cohort study was conducted using secondary data from DFI inpatients from 1 January 2018 to 31 May 2020, from Dr. Cipto Mangunkusumo Hospital (RSCM), the National Referral Hospital of Indonesia. The Gyssens algorithm was used to help assess the appropriateness of antibiotics. All subjects were type 2 Diabetes Mellitus (T2DM) adult patients diagnosed with DFI. The primary outcome was a clinical improvement of infection after 7 - 14 days of antibiotic use. The clinical improvement of infection was defined by a minimum of three of these criteria: reduced or no purulent secretions, no fever, the area around the wound did not feel warm, no or reduced local oedema, no local pain, reduced redness or erythema, and decreased leukocytes count.

RESULTS

A total of 113 (63.5%) eligible subjects from a total of 178 were recruited. Among the patients, 51.4% had a duration of T2DM for ≥10 years, 60.2% had uncontrolled hyperglycemia, 94.7% had a history of complications, 22.1% had a history of amputation, and 72.6% had ulcer grade ≥3. Based on the Gyssens algorithm, 54.0% of the subjects were given antibiotics appropriately, while the other 46.0% were not. The proportion of improved patients in the appropriate antibiotics group was higher but not statistically significant than those in the inappropriate group (60.7% vs. 42.3%, P = 0.079). However, the results of the multivariate analysis demonstrated that the appropriate use of antibiotics would increase clinical improvement by 2.6 times, compared to inappropriate use after controlling for the covariates (adjusted odds ratio: 2.616, 95% confidence interval: 1.117 - 6.126, P = 0.027).

CONCLUSION

Only half of the patients with DFI received appropriate antibiotics, although an appropriate antibiotics usage was independently associated with better short-term clinical improvement in DFI. This suggests that we should effort to improve appropriateness in antibiotics usage in DFI.