Urinary tract infections and antibiotic use in pregnancy - qualitative analysis of online forum content

Emergency department overcrowding and its associated factors at HARME medical emergency center in Eastern Ethiopia

Introduction

Emergency department (ED) overcrowding has become a significant concern as it can lead to compromised patient care in emergency settings. Various tools have been used to evaluate overcrowding in ED. However, there is a lack of data regarding this issue in resource-limited countries, including Ethiopia. This study aimed to validate NEDOCS, assess level of ED overcrowding and identify associated factors at HARME Medical Emergency Center, located in Hiwot Fana Comprehensive Specialized Hospital, Harar, Ethiopia.

Methods

A cross-sectional study was conducted at the HARME Medical Emergency Center, Hiwot Fana Comprehensive Specialized Hospital, involving a total of 899 patients during 120 sampling intervals. The area under the receiver operating characteristic curves (AUC) was calculated to evaluate the agreement between objective and subjective assessments of ED overcrowding. A multivariable logistic regression analysis was employed to identify factors associated with ED overcrowding and statistically significant association was declared using 95 % confidence level and a p-value < 0.05.

Results

The interrater agreement showed a strong correlation with a Cohen's kappa (κ) of 0.80. The National Emergency Department Overcrowding Study Score demonstrated a strong association with subjective assessments from residents and case team nurses, with an AUC of 0.81 and 0.79, respectively. According to residents' perceptions, ED were considered overcrowded 65.8 % of the time. Factors significantly associated with ED overcrowding included waiting time for triage (AOR: 2.24; 95 % CI: 1.54-3.27), working time (AOR: 2.23; 95 % CI: 1.52-3.26), length of stay (AOR: 2.40; 95 % CI: 1.27-4.54), saturation level (AOR: 2.35; 95 % CI: 1.31-4.20), chronic illness (AOR: 2.19; 95 % CI: 1.37-3.53), and abnormal pulse rate (AOR: 1.52; 95 % CI: 1.06-2.16).

Conclusion

The study revealed that ED were overcrowded approximately two-thirds of the time.

Psychosocial impact of recurrent urogenital infections: a review

Recurrent urogenital infections such as bacterial vaginosis, vulvovaginal candidiasis, and urinary tract infections have a high prevalence and pronounced psychosocial impact. However, no review has compared the psychosocial impacts across infection types. This narrative review discusses the impact of common recurrent urogenital infections on psychosocial aspects, including quality of life, stress, mental health, sexual health, work productivity, race and ethnicity, and satisfaction of medical care. Validated questionnaires show that women with recurrent vulvovaginal candidiasis and urinary tract infections have decreased scores on all aspects of quality of life. Those with recurrent vulvovaginal candidiasis and urinary tract infections show lower mental health scores compared to the general population, with increased risk of anxiety and depression. Recurrent urogenital infections affect sexual relationships and intimacy, including avoidance due to symptoms or as a method of prevention. Recurrent infections also increase medical cost and negatively affect work productivity, leading to a combined estimated cost of over US$13 billion per year. There are clear effects of racial inequality involving minority populations that affect diagnosis, treatment, prevalence, and reporting of recurrent urogenital infections. Satisfactory medical treatment improves quality of life and mental health in those suffering from these conditions. Research evaluating psychosocial aspects of recurrent urogenital infections is variable and is not comparable across vulvovaginal conditions. Even so, psychosocial factors are important in understanding contribution and consequence of urogenital infections. Education, awareness, normalization, community support, and access to care can help to alleviate the negative implications of recurrent urogenital infections.

Perceptions and reported practices of pregnant women and mothers of children under two years of age regarding antibiotic use and resistance in Vientiane province, Lao PDR: a qualitative study

BACKGROUND

Understanding pregnant women and mothers' perceptions towards antibiotic use and resistance is essential for appropriate antibiotic use and limiting antibiotic resistance. This study aimed to explore perceptions and reported practices of pregnant women and mothers with children under two years of age regarding correct antibiotic use and antibiotic resistance in Vientiane Province, Lao PDR.

METHODS

The study employed an exploratory qualitative research design using focus groups discussions (FGDs). Participants were purposively selected based on: being pregnant at third trimester and attending antenatal care and mothers with children under two years of age, attending the health facility for postpartum visit /vaccinations. Six focus group discussions were conducted in September 2019 with a total of 55 women. The FGDs were transcribed verbatim, data were analyzed first by coding then categorizing the data as we looked for patterns and themes by using the qualitative content analysis.

RESULTS

Most participants had some understanding of antibiotics but wrongly believed antibiotics can be used to treat viral disease. Over half of the participants had heard the term "antibiotic resistance", but often believed it was their bodies, not the bacteria that developed antibiotic resistance. During pregnancy and for their infants, women preferred to use antibiotics only when prescribed by a doctor. Outside of pregnancy however, consuming antibiotics without a prescription was commonly reported. Participants wanted more information about the indications for antibiotic use and antibiotic resistance.

CONCLUSIONS

More effort is required to increase the level of understanding, and practice of mothers to promote optimal antibiotic use. Mothers' desire to learn more, and their fundamental concern for their children, can be used to promote appropriate antibiotic use. Awareness raising should be complemented by efforts to address other determinants of inappropriate antibiotic use, including educating healthcare workers, and pharmacists and addressing health service determinants that contribute to inappropriate antibiotic use.

Examination of Complementary Medicine for Treating Urinary Tract Infections Among Pregnant Women and Children

Urinary tract infections (UTIs) are a significant clinical problem that pregnant women and children commonly experience. Escherichia coli is the primary causative organism, along with several other gram-negative and gram-positive bacteria. Antimicrobial drugs are commonly prescribed to treat UTIs in these patients. Conventional treatment can range from using broad-spectrum antimicrobial drugs for empirical or prophylactic therapy or patient-tailored therapy based on urinary cultures and sensitivity to prospective antibiotics. The ongoing emergence of multi-drug resistant pathogens has raised concerns related to commonly prescribed antimicrobial drugs such as those used routinely to treat UTIs. Consequently, several natural medicines have been explored as potential complementary therapies to improve health outcomes in patients with UTIs. This review discusses the effectiveness of commonly used natural products such as cranberry juice/extracts, ascorbic acid, hyaluronic acid, probiotics, and multi-component formulations intended to treat and prevent UTIs. The combination of natural products with prescribed antimicrobial treatments and use of formulations that contained high amounts of cranberry extracts appear to be most effective in preventing recurrent UTIs (RUTIs). The incorporation of natural products like cranberry, hyaluronic acid, ascorbic acid, probiotics, Canephron® N, and Cystenium II to conventional treatments of acute UTIs or as a prophylactic regimen for treatment RUTIs can benefit both pregnant women and children. Limited information is available on the safety of natural products in these patients' populations. However, based on limited historical information, these remedies appear to be safe and well-tolerated by patients.

Experiences of urinary tract infection: A systematic review and meta-ethnography

AIM

To understand the experience of urinary tract infection (UTI) by synthesizing primary qualitative research findings and developing a conceptual model that illustrates this experience.

METHOD

A systematic search of Medline, PsychInfo, Embase, and CINAHL from inception to August 2020 to find qualitative research exploring the experience of UTI. Qualitative evidence synthesis in the form of meta-ethnography was undertaken. Findings are reported in keeping with eMERGe guidance.

RESULTS

We included 16 qualitative studies in the synthesis of evidence, providing data from over 1038 participants aged 13-97 years. We developed nine themes: the impact of UTI on my whole body; impact on quality of life, activities, and the associated psychological toll; I know my body and my experience has taught me when I need to seek care; worry and the transition to medicalization; antibiotics are a valuable treatment approach; antibiotics are a last resort; being heard, seen, and cared for with dignity; self-judgment; and the end of the road, a need for information and cure. These themes supported a conceptual model to illustrate the patient experience of UTI.

CONCLUSIONS

The conceptual model communicates the wide and varied symptoms of patients' UTI experiences and how they process this and make care decision based on past health experiences. For some, there appears to be a sense of hopelessness and frustration. This model may be used to highlight the need for improvements in diagnostic and treatment pathways. Future research to further understand the nuances of acute, recurrent, and persistent UTI is needed.

Using Large-scale Social Media Analytics to Understand Patient Perspectives About Urinary Tract Infections: Thematic Analysis

Background

Current qualitative literature about the experiences of women dealing with urinary tract infections (UTIs) is limited to patients recruited from tertiary centers and medical clinics. However, traditional focus groups and interviews may limit what patients share. Using digital ethnography, we analyzed free-range conversations of an online community.

Objective

This study aimed to investigate and characterize the patient perspectives of women dealing with UTIs using digital ethnography.

Methods

A data-mining service was used to identify online posts. A thematic analysis was conducted on a subset of the identified posts. Additionally, a latent Dirichlet allocation (LDA) probabilistic topic modeling method was applied to review the entire data set using a semiautomatic approach. Each identified topic was generated as a discrete distribution over the words in the collection, which can be thought of as a word cloud. We also performed a thematic analysis of the word cloud topic model results.

Results

A total of 83,589 posts by 53,460 users from 859 websites were identified. Our hand-coding inductive analysis yielded the following 7 themes: quality-of-life impact, knowledge acquisition, support of the online community, health care utilization, risk factors and prevention, antibiotic treatment, and alternative therapies. Using the LDA topic model method, 105 themes were identified and consolidated into 9 categories. Of the LDA-derived themes, 25.7% (27/105) were related to online community support, and 22% (23/105) focused on UTI risk factors and prevention strategies.

Conclusions

Our large-scale social media analysis supports the importance and reproducibility of using online data to comprehend women’s UTI experience. This inductive thematic analysis highlights patient behavior, self-empowerment, and online media utilization by women to address their health concerns in a safe, anonymous way.

Antibiotic use amongst pregnant women in a public hospital in KwaZulu-Natal

Background

Antibiotics are amongst the more frequently prescribed medicines in pregnant women and the use of antibiotics is increasing. However, with limited studies available in this population, the safe use of antibiotics in pregnancy remains a concern.

Aim

To evaluate the use of antibiotics amongst pregnant women attending a public health care facility. The main objective of this study was to quantify the types of antibiotics used in pregnant women.

Setting

A public hospital classified as a referral hospital located in Durban, KwaZulu-Natal.

Methods

Demographic and treatment information of women were collected retrospectively from January 2019 to July 2019. A total of 184 pregnant patients, who received antibiotic therapy, were included in this study. Descriptive and analytical measures were used to analyse both patient demographics and treatment variables.

Results

A total of 416 antibiotic prescriptions, issued to 184 patients, were reviewed. Penicillins (39.7%), macrolides (13.0%) and combination penicillin- and beta-lactam inhibitors (12.3%) were reported as the most commonly prescribed antibiotics. Rifamycin (2.9%), hydrazides (2.2%) and aminoglycosides (1.9%) were less frequently prescribed. Most antibiotics were prescribed for diseases of the circulatory system (36.1%).

Conclusion

Several classes of antibiotics were used in pregnancy despite the lack of available safety data and clinical evidence. Informing women of the potential side effects and keeping abreast with new information played an important role in the safe, rational and effective use of medicines that contributed to improving maternal health.

Antibiotic Prescriptions among China Ambulatory Care Visits of Pregnant Women: A Nationwide Cross-Sectional Study

BACKGROUND

Antibiotic use in pregnant women at the national level has rarely been reported in China.

OBJECTIVES

We aimed to investigate antibiotic prescriptions during pregnancy in ambulatory care settings in China.

METHODS

Data of 4,574,961 ambulatory care visits of pregnant women from October 2014 to April 2018 were analyzed. Percentages of Antibiotic prescriptions by different subgroups and various diagnosis categories and proportions of inappropriate antibiotic prescriptions for different subgroups were estimated. Food and Drug Administration (FDA) pregnancy categories were used to describe the antibiotic prescription patterns. The 95% confidence intervals (CIs) were estimated using the Clopper--Pearson method or Goodman method.

RESULTS

Among the 4,574,961 outpatient visits during pregnancy, 2.0% (92,514 visits; 95% CI, 2.0-2.0%) were prescribed at least one antibiotic. The percentage of antibiotic prescriptions for pregnant women aged >40 years was 4.9% (95% CI, 4.7-5.0%), whereas that for pregnant women aged 26-30 years was 1.5% (95% CI, 1.4-1.5%). In addition, percentages of antibiotic prescriptions varied among different trimesters of pregnancy, which were 5.4% (95% CI, 5.3-5.4%) for the visits in the first trimester of pregnancy and 0.5% (95% CI, 0.4-0.5%) in the third trimester of pregnancy. Furthermore, the percentages of antibiotic prescriptions substantially varied among different diagnosis categories and nearly three-quarters of antibiotic prescriptions had no clear indications and thus might be inappropriate. In total, 130,308 individual antibiotics were prescribed; among these, 60.4% (95% CI, 60.0-60.8%) belonged to FDA category B, 2.7% (95% CI, 2.1-3.5%) were classified as FDA category D and 16.8% (95% CI, 16.2-17.4%) were not assigned any FDA pregnancy category.

CONCLUSIONS

Antibiotic prescriptions in ambulatory care during pregnancy were not highly prevalent in mainland China. However, a substantial proportion of antibiotics might have been prescribed without adequate indications. Antibiotics whose fetal safety has not been sufficiently illustrated were widely used in pregnant women.

Understanding farmers' naturalistic decision making around prophylactic antibiotic use in lambs using a grounded theory and natural language processing approach

The routine use of antibiotics for prevention of disease in neonatal lambs has been highlighted as inappropriate, yet research suggests that many farmers in the UK still carry out this practice. The aim of the study was to understand farmers' naturalistic decision-making around prophylactic antibiotic use in lambs. Data from 431 posts by 133 different users of an online discussion forum were analysed quantitatively using natural language processing and qualitatively using a grounded theory approach. Results from the qualitative analysis identified five categories that influenced farmers risk perceptions around prophylactic antibiotic use in lambs: anticipated regret, negative emotions and experiential avoidance; economic considerations; farmer identity; perception of capability; and perception of social judgement. Natural language processing analysis of the posts by the study group were compared to posts on topics unrelated to antibiotic use by control groups from the same forum to understand the underlying style and tone within the text. Analytical thinking and authenticity scores were significantly lower in the study group compared to the control groups (P < 0.01). Words relating to cognitive processes were significantly higher in the study group compared to the control groups (P < 0.01). Results of the qualitative and quantitative analysis were integrated to assess the fit of the data and enhance findings from either method alone. The key findings were the identification of reasons why farmers used antibiotics prophylactically in neonatal lambs. Farmers disassociated the use of oral antibiotics in neonatal lambs from other types of antibiotics within sheep farming. Farmers used the concept of luck and uniqueness to justify their prophylactic antibiotic use. This may explain farmers' low analytical thinking scores as this reflects a more personal style of thinking as farmers express their thoughts on antibiotic use on an individual basis. Farmers' felt that they did not have the capabilities to control neonatal disease without antibiotics during busy periods and this was exacerbated by external economic constraints. For farmers' who used antibiotics for therapeutic use, fear of social judgement was an important factor in their perceptions of risk around antibiotic use. The high frequency of negations and conjunctions suggested feelings of moral duty. As such, antibiotic use has developed into a symbol of their good farming identity which conflicted with the identity held by those who used antibiotics prophylactically. These results can be used to inform knowledge exchange around prophylactic antibiotic use in lambs to improve antibiotic stewardship in the sheep farming sector.

Antibiotic Prescribing in Primary Care for Urinary Tract Infections (UTIs) in Pregnancy: An Audit Study

Urinary tract infections (UTIs) are associated with negative pregnancy outcomes and are treated with antibiotics. Although beneficial, antibiotic use causes antimicrobial resistance (AMR), and therefore their use needs to be carefully balanced. Antimicrobial guidelines are developed to facilitate appropriate prescribing of antibiotics. This study assessed antibiotic prescribing for UTIs in pregnancy against the National Institute for Health and Care Excellence (NICE) guideline NG109. Fifty antibiotic prescribing records dated from 1st October 2018 to 1st July 2019 were identified from three London-based GP practices. The results show that a mid-stream sample of urine, which is important for the review and tailoring of antibiotic treatment, was collected in 77.6% of cases. Prescribing the first-line antibiotic is important for adequate treatment and good antimicrobial stewardship and results show that 44% of prescriptions were for the first-choice antibiotic. Most prescriptions (56%) were for a second-line or non-recommended antibiotic. Providing self-care advice is key to empowering pregnant women in managing their own health but only 16% of records documented provision of self-care advice. This study highlights important areas of concern in the management of UTIs in pregnancy. However, due to the retrospective design, future work is needed to evaluate the role of AMR in the prescriber’s treatment decision-making process.

'There is no choice apart from antibiotics…': Qualitative analysis of views on urinary infections in pregnancy and antimicrobial resistance

BACKGROUND

Antimicrobial resistance (AMR) is a health risk as it can lead to life-threatening infections. There has been a rise in resistant urinary tract infections (UTIs) which is the most common infection in pregnancy. This can be challenging in pregnancy due to the additional need to safeguard foetal development. The study's aim was to explore views about AMR in women who experienced UTIs in pregnancy.

DESIGN

Fifteen semi-structured interviews were conducted in the UK and analysed using thematic analysis.

RESULTS

Results highlighted two themes: conceptualization of AMR and pregnancy as a deviation from the norm, with an overarching theme of 'self-efficacy'. Results show that participants were concerned about AMR but uncertain about the effect on society compared to individual's taking antibiotics and about completing antibiotic courses. Participants reported an unsparing use of antibiotics was justified in pregnancy, and behaviours like drinking adequate water were ineffective at preventing UTIs. In summary, women had low self-efficacy regards tackling AMR and managing their health.

CONCLUSION

Misconceptions about how AMR affects society vs the individual translated into viewing it as a future problem to be tackled by the health-care sector. Consequently, AMR requires reconceptualization as a current problem requiring collective action. This research also indicates women endorse a biomedical model of UTIs in pregnancy which attributes resolving illness to interventions such as medicines, implying an automatic reliance on antibiotics. Subsequently, there is a need for self-efficacy by focusing on a behavioural model which emphasizes behaviours for infection prevention, thus reducing the need for antibiotics.