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Prieto J, Wilson J, Tingle A, Cooper E, Handley M, Rycroft Malone J, Bostock J, Loveday H. Preventing urinary tract infection in older people living in care homes: the 'StOP UTI' realist synthesis. BMJ Qual Saf 2024:bmjqs-2023-016967. [PMID: 39122359 DOI: 10.1136/bmjqs-2023-016967] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Accepted: 08/01/2024] [Indexed: 08/12/2024]
Abstract
BACKGROUND Urinary tract infection (UTI) is the most diagnosed infection in older people living in care homes. OBJECTIVE To identify interventions for recognising and preventing UTI in older people living in care homes in the UK and explain the mechanisms by which they work, for whom and under what circumstances. METHODS A realist synthesis of evidence was undertaken to develop programme theory underlying strategies to recognise and prevent UTI. A generic topic-based search of bibliographic databases was completed with further purposive searches to test and refine the programme theory in consultation with stakeholders. RESULTS 56 articles were included in the review. Nine context-mechanism-outcome configurations were developed and arranged across three theory areas: (1) Strategies to support accurate recognition of UTI, (2) care strategies for residents to prevent UTI and (3) making best practice happen. Our programme theory explains how care staff can be enabled to recognise and prevent UTI when this is incorporated into care routines and activities that meet the fundamental care needs and preferences of residents. This is facilitated through active and visible leadership by care home managers and education that is contextualised to the work and role of care staff. CONCLUSIONS Care home staff have a vital role in preventing and recognising UTI in care home residents.Incorporating this into the fundamental care they provide can help them to adopt a proactive approach to preventing infection and avoiding unnecessary antibiotic use. This requires a context of care with a culture of personalisation and safety, promoted by commissioners, regulators and providers, where leadership and resources are committed to support preventative action by knowledgeable care staff.
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Affiliation(s)
| | - Jennie Wilson
- Richard Wells Research Centre, University of West London-Brentford Site, Brentford, UK
| | - Alison Tingle
- Richard Wells Research Centre, University of West London-Brentford Site, Brentford, UK
| | | | | | | | | | - Heather Loveday
- Richard Wells Research Centre, University of West London-Brentford Site, Brentford, UK
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Ciaccio L, Fountain H, Beech E, Brown CS, Demirjian A, Gerver S, Muller-Pebody B, Bou-Antoun S. Trends in urine sampling rates of general practice patients with suspected lower urinary tract infections in England, 2015-2022: a population-based study. BMJ Open 2024; 14:e084485. [PMID: 39107033 PMCID: PMC11308898 DOI: 10.1136/bmjopen-2024-084485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Accepted: 07/03/2024] [Indexed: 08/09/2024] Open
Abstract
OBJECTIVES Inappropriate prescribing of antibiotics is a key driver of antimicrobial resistance. This study aimed to describe urine sampling rates and antibiotic prescribing for patients with lower urinary tract infections (UTIs) in English general practice. DESIGN A retrospective population-based study using administrative data. SETTING IQVIA Medical Research Database (IMRD) data from general practices in England, 2015-2022. PARTICIPANTS Patients who have consulted with an uncomplicated UTI in England general practices captured in the IMRD. OUTCOME MEASURES Trends in UTI episodes (episodes were defined as UTI diagnosis codes occurring within 14 days of each other), testing and antibiotic prescribing on the same day as initial UTI consultation were assessed from January 2015 to December 2022. Associations, using univariate and multivariate logistic regressions, were examined between consultation and demographic factors on the odds of a urine test. RESULTS There were 743 350 UTI episodes; 50.8% had a urine test. Testing rates fluctuated with an upward trend and large decline in 2020. Same-day UTI antibiotic prescribing occurred in 78.2% of episodes. In multivariate modelling, factors found to decrease odds of a urine test included age ≥85 years (0.83, 95% CI 0.82 to 0.84), consultation type (remote vs face to face, 0.45, 95% CI 0.45 to 0.46), episodes in London compared with the South (0.74, 95% CI 0.72 to 0.75) and increasing practice size (0.77, 95% CI 0.76 to 0.78). Odds of urine tests increased in males (OR 1.11, 95% CI 1.10 to 1.13), for those episodes without a same-day UTI antibiotic (1.10, 95% CI 1.04 to 1.16) for episodes for those with higher deprivation status (Indices of Multiple Deprivation 8 vs 1, 1.51, 95% CI 1.48 to 1.54). Compared with 2015, 2016-2019 saw increased odds of testing while 2020 and 2021 saw decreases, with 2022 showing increased odds. CONCLUSION Urine testing for UTI in general practice in England showed an upward trend, with same-day antibiotic prescribing remaining consistent, suggesting greater alignment to national guidelines. The COVID-19 pandemic impacted testing rates, though as of 2022, they began to recover.
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Affiliation(s)
- Laura Ciaccio
- Division of Population Health and Genomics, University of Dundee School of Medicine, Dundee, UK
- Healthcare-Associated Infection (HCAI), Fungal, Antimicrobial Resistance (AMR), Antimicrobial Use (AMU) & Sepsis Division, UK Health Security Agency, London, UK
| | - Holly Fountain
- Healthcare-Associated Infection (HCAI), Fungal, Antimicrobial Resistance (AMR), Antimicrobial Use (AMU) & Sepsis Division, UK Health Security Agency, London, UK
| | | | - Colin S Brown
- Healthcare-Associated Infection (HCAI), Fungal, Antimicrobial Resistance (AMR), Antimicrobial Use (AMU) & Sepsis Division, UK Health Security Agency, London, UK
- UKHSA and NIHR Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, London, UK
| | - Alicia Demirjian
- Healthcare-Associated Infection (HCAI), Fungal, Antimicrobial Resistance (AMR), Antimicrobial Use (AMU) & Sepsis Division, UK Health Security Agency, London, UK
- Department of Paediatric Infectious Diseases & Immunology, Evelina London Children's Hospital, London, UK
- Faculty of Life Sciences & Medicine, King’s College London, London, UK
| | - Sarah Gerver
- Healthcare-Associated Infection (HCAI), Fungal, Antimicrobial Resistance (AMR), Antimicrobial Use (AMU) & Sepsis Division, UK Health Security Agency, London, UK
| | - Berit Muller-Pebody
- Healthcare-Associated Infection (HCAI), Fungal, Antimicrobial Resistance (AMR), Antimicrobial Use (AMU) & Sepsis Division, UK Health Security Agency, London, UK
- UKHSA and NIHR Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, London, UK
| | - Sabine Bou-Antoun
- Healthcare-Associated Infection (HCAI), Fungal, Antimicrobial Resistance (AMR), Antimicrobial Use (AMU) & Sepsis Division, UK Health Security Agency, London, UK
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Schoffelen T, Papan C, Carrara E, Eljaaly K, Paul M, Keuleyan E, Martin Quirós A, Peiffer-Smadja N, Palos C, May L, Pulia M, Beovic B, Batard E, Resman F, Hulscher M, Schouten J. European Society of Clinical Microbiology and Infectious Diseases (ESCMID) guidelines for Antimicrobial Stewardship in Emergency Departments (endorsed by European Association of Hospital Pharmacists). Clin Microbiol Infect 2024:S1198-743X(24)00251-9. [PMID: 39029872 DOI: 10.1016/j.cmi.2024.05.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Revised: 05/24/2024] [Accepted: 05/26/2024] [Indexed: 07/21/2024]
Abstract
SCOPE This ESCMID guideline provides evidence-based recommendations to support a selection of appropriate antibiotic use practices for patients seen in the emergency department (ED) and guidance for their implementation. The topics addressed in this guideline are: 1) Do biomarkers or rapid pathogen tests improve antibiotic prescribing and/or clinical outcomes? 2) Does taking blood cultures in common infectious syndromes improve antibiotic prescribing and/or clinical outcomes? 3) Does watchful waiting without antibacterial therapy or with delayed antibiotic prescribing reduce antibiotic prescribing without worsening clinical outcomes in patients with specific infectious syndromes? 4) Do structured culture follow-up programs in patients discharged from the ED with cultures pending improve antibiotic prescribing? METHODS An expert panel was convened by ESCMID and the guideline chair. The panel selected in consensus the four most relevant AMS topics according to pre-defined relevance criteria. For each main question for the four topics, a systematic review was performed, including randomized controlled trials and observational studies. Both clinical outcomes as well as stewardship process outcomes related to antibiotic use were deemed relevant. The literature searches were conducted between May 2021 and March 2022. In April 2022, the panel members were formally asked to suggest additional studies that were not identified in the initial searches. Data were summarized in a meta-analysis if possible or otherwise summarized narratively. The certainty of the evidence was classified according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) criteria. The guideline panel reviewed the evidence per topic critically appraising the evidence and formulated recommendations through a consensus-based process. The strength of the recommendations was classified as strong or weak. To substantiate the implementation process, implementation trials or observational studies describing facilitators/barriers for implementation were identified from the same searches and were summarized narratively. RECOMMENDATIONS The recommendations on the use of biomarkers and rapid pathogen diagnostic tests focus on the initiation of antibiotics in patients admitted through the ED. Their effect on the discontinuation or de-escalation of antibiotics during hospital stay was not reported, neither was their effect on hospital infection prevention and control practices. The recommendations on watchful waiting (i.e., withholding antibiotics with some form of follow-up) focus on specific infectious syndromes for which the primary care literature was also included. The recommendations on blood cultures focus on the indication in three common infectious syndromes in the ED explicitly excluding patients with sepsis or septic shock. Most recommendations are based on very-low- and low-certainty of evidence, leading to weak recommendations or, when no evidence was available, to best practice statements. Implementation of these recommendations needs to be adapted to the specific settings and circumstances of the ED. The scarcity of high-quality studies in the area of antimicrobial stewardship in the ED highlights the need for future research in this field.
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Affiliation(s)
- Teske Schoffelen
- Radboud Center for Infectious Diseases, Radboud university medical center, Nijmegen, the Netherlands; Department of Internal Medicine, Radboud university medical center, Nijmegen, the Netherlands.
| | - Cihan Papan
- Institute for Hygiene and Public Health, University Hospital Bonn, Bonn, Germany; Centre for Infectious Diseases, Institute of Medical Microbiology and Hygiene, Saarland University, Homburg, Germany
| | - Elena Carrara
- Division of Infectious Diseases, Department of Diagnostic and Public Health, University of Verona, Verona, Italy
| | - Khalid Eljaaly
- Department of Pharmacy Practice, College of Pharmacy, King Abdulaziz University, Jeddah, Saudi Arabia; King Abdulaziz University Hospital, Jeddah, Saudi Arabia
| | - Mical Paul
- Infectious Diseases, Rambam Health Care Campus, Faculty of Medicine, Technion - Israel Institute of Technology, Haifa, Israel
| | - Emma Keuleyan
- Department of Clinical Microbiology and Virology, University Hospital Lozenetz, Sofia, Bulgaria; Ministry of Health, Sofia, Bulgaria
| | | | - Nathan Peiffer-Smadja
- Infectious Diseases Department, Bichat-Claude Bernard Hospital, Assistance-Publique Hôpitaux de Paris, Paris, France; Université Paris Cité, INSERM, IAME, F-75018 Paris, France; National Institute for Health Research, Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, London, UK
| | - Carlos Palos
- Hospital da Luz, Infection Control and Antimicrobial Resistance Committee, Lisbon, Portugal
| | - Larissa May
- University of California Davis, Department of Emergency Medicine, Sacramento, CA, USA
| | - Michael Pulia
- BerbeeWalsh Department of Emergency Medicine, University of Wisconsin Madison School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Bojana Beovic
- Faculty of Medicine, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Eric Batard
- Emergency Department, CHU Nantes, Nantes, France; Cibles et médicaments des infections et du cancer, IICiMed UR1155, Nantes Université, Nantes, France
| | - Fredrik Resman
- Clinical Infection Medicine, Department of Translational Medicine, Lund University, Malmö, Sweden
| | - Marlies Hulscher
- IQ Health science department, Radboud university medical center, Nijmegen, the Netherlands
| | - Jeroen Schouten
- Radboud Center for Infectious Diseases, Radboud university medical center, Nijmegen, the Netherlands; Department of Intensive Care Medicine, Radboud university medical center, Nijmegen, the Netherlands
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Knowles R, Chandler C, O’Neill S, Sharland M, Mays N. A systematic review of national interventions and policies to optimize antibiotic use in healthcare settings in England. J Antimicrob Chemother 2024; 79:1234-1247. [PMID: 38507232 PMCID: PMC11144483 DOI: 10.1093/jac/dkae061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2023] [Accepted: 02/19/2024] [Indexed: 03/22/2024] Open
Abstract
OBJECTIVES To identify and assess the effectiveness of national antibiotic optimization interventions in primary and secondary care in England (2013-2022). METHODS A systematic scoping review was conducted. Literature databases (Embase and Medline) were used to identify interventions and evaluations. Reports included the UK AMR Strategy (2013-2018), National Action Plan (2019-2024) and English Surveillance Programme for Antimicrobial Utilisation and Resistance (ESPAUR) reports (2014-2022). The design, focus and quality of evaluations and the interventions' effectiveness were extracted. FINDINGS Four hundred and seventy-seven peer-reviewed studies and 13 reports were screened. One hundred and three studies were included for review, identifying 109 interventions in eight categories: policy and commissioning (n = 9); classifications (n = 1); guidance and toolkits (n = 22); monitoring and feedback (n = 17); professional engagement and training (n = 19); prescriber tools (n = 12); public awareness (n = 17); workforce and governance (n = 12).Most interventions lack high-quality effectiveness evidence. Evaluations mainly focused on clinical, microbiological or antibiotic use outcomes, or intervention implementation, often assessing how interventions were perceived to affect behaviour. Only 16 interventions had studies that quantified effects on prescribing, of which six reported reductions. The largest reduction was reported with structural-level interventions and attributed to a policy and commissioning intervention (primary care financial incentives). Behavioural interventions (guidance and toolkits) reported the greatest impact in hospitals. CONCLUSIONS Many interventions have targeted antibiotic use, each pulling different levers across the health system simultaneously. On the basis of these studies, structural-level interventions may have the greatest impact. Collectively, the combination of interventions may explain England's decline in prescribing but direct evidence of causality is unavailable.
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Affiliation(s)
- Rebecca Knowles
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Clare Chandler
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
| | - Stephen O’Neill
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Mike Sharland
- Centre for Neonatal and Paediatric Infection, Institute for Infection and Immunity, St George’s, University of London, London, UK
- Paediatric Infectious Diseases Department, St George’s University Hospitals NHS Foundation Trust, London, UK
| | - Nicholas Mays
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
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5
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Lai H, Kolanko M, Li LM, Parkinson ME, Bourke NJ, Graham NSN, David MCB, Mallas EJ, Su B, Daniels S, Wilson D, Golemme M, Norman C, Jensen K, Jackson R, Tran M, Freemont PS, Wingfield D, Wilkinson T, Gregg EW, Tzoulaki I, Sharp DJ, Soreq E. Population incidence and associated mortality of urinary tract infection in people living with dementia. J Infect 2024; 88:106167. [PMID: 38679203 DOI: 10.1016/j.jinf.2024.106167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Revised: 03/03/2024] [Accepted: 04/20/2024] [Indexed: 05/01/2024]
Abstract
OBJECTIVES Urinary tract infections (UTIs) frequently cause hospitalisation and death in people living with dementia (PLWD). We examine UTI incidence and associated mortality among PLWD relative to matched controls and people with diabetes and investigate whether delayed or withheld treatment further impacts mortality. METHODS Data were extracted for n = 2,449,814 people aged ≥ 50 in Wales from 2000-2021, with groups matched by age, sex, and multimorbidity. Poisson regression was used to estimate incidences of UTI and mortality. Cox regression was used to study the effects of treatment timing. RESULTS UTIs in dementia (HR=2.18, 95 %CI [1.88-2.53], p < .0) and diabetes (1.21[1.01-1.45], p = .035) were associated with high mortality, with the highest risk in individuals with diabetes and dementia (both) (2.83[2.40-3.34], p < .0) compared to matched individuals with neither dementia nor diabetes. 5.4 % of untreated PLWD died within 60 days of GP diagnosis-increasing to 5.9 % in PLWD with diabetes. CONCLUSIONS Incidences of UTI and associated mortality are high in PLWD, especially in those with diabetes and dementia. Delayed treatment for UTI is further associated with high mortality.
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Affiliation(s)
- Helen Lai
- UK Dementia Research Institute Care Research and Technology Centre (UK DRI CR&T) at Imperial College London and the University of Surrey, Imperial College London, White City Campus, 86 Wood Lane, London W12 0BZ, UK; Department of Brain Sciences, Faculty of Medicine, Imperial College London, Hammersmith Hospital, Du Cane Road, London W12 0NN, UK
| | - Magdalena Kolanko
- UK Dementia Research Institute Care Research and Technology Centre (UK DRI CR&T) at Imperial College London and the University of Surrey, Imperial College London, White City Campus, 86 Wood Lane, London W12 0BZ, UK; Department of Brain Sciences, Faculty of Medicine, Imperial College London, Hammersmith Hospital, Du Cane Road, London W12 0NN, UK
| | - Lucia M Li
- UK Dementia Research Institute Care Research and Technology Centre (UK DRI CR&T) at Imperial College London and the University of Surrey, Imperial College London, White City Campus, 86 Wood Lane, London W12 0BZ, UK; Department of Brain Sciences, Faculty of Medicine, Imperial College London, Hammersmith Hospital, Du Cane Road, London W12 0NN, UK
| | - Megan E Parkinson
- UK Dementia Research Institute Care Research and Technology Centre (UK DRI CR&T) at Imperial College London and the University of Surrey, Imperial College London, White City Campus, 86 Wood Lane, London W12 0BZ, UK; Perioperative and Ageing Group, Imperial College London, South Kensington Campus, London SW7 2AZ, UK
| | - Niall J Bourke
- Department of Brain Sciences, Faculty of Medicine, Imperial College London, Hammersmith Hospital, Du Cane Road, London W12 0NN, UK; Institute of Psychiatry, Psychology & Neuroscience (IoPPN), King's College London, 16 De Crespigny Park, London SE5 8AB, UK
| | - Neil S N Graham
- UK Dementia Research Institute Care Research and Technology Centre (UK DRI CR&T) at Imperial College London and the University of Surrey, Imperial College London, White City Campus, 86 Wood Lane, London W12 0BZ, UK; Department of Brain Sciences, Faculty of Medicine, Imperial College London, Hammersmith Hospital, Du Cane Road, London W12 0NN, UK
| | - Michael C B David
- UK Dementia Research Institute Care Research and Technology Centre (UK DRI CR&T) at Imperial College London and the University of Surrey, Imperial College London, White City Campus, 86 Wood Lane, London W12 0BZ, UK; Department of Brain Sciences, Faculty of Medicine, Imperial College London, Hammersmith Hospital, Du Cane Road, London W12 0NN, UK
| | - Emma-Jane Mallas
- UK Dementia Research Institute Care Research and Technology Centre (UK DRI CR&T) at Imperial College London and the University of Surrey, Imperial College London, White City Campus, 86 Wood Lane, London W12 0BZ, UK; Department of Brain Sciences, Faculty of Medicine, Imperial College London, Hammersmith Hospital, Du Cane Road, London W12 0NN, UK
| | - Bowen Su
- Department of Epidemiology and Biostatistics, School of Public Health, Imperial College London, South Kensington Campus, London SW7 2AZ, UK
| | - Sarah Daniels
- UK Dementia Research Institute Care Research and Technology Centre (UK DRI CR&T) at Imperial College London and the University of Surrey, Imperial College London, White City Campus, 86 Wood Lane, London W12 0BZ, UK; Department of Brain Sciences, Faculty of Medicine, Imperial College London, Hammersmith Hospital, Du Cane Road, London W12 0NN, UK
| | - Danielle Wilson
- UK Dementia Research Institute Care Research and Technology Centre (UK DRI CR&T) at Imperial College London and the University of Surrey, Imperial College London, White City Campus, 86 Wood Lane, London W12 0BZ, UK; Department of Brain Sciences, Faculty of Medicine, Imperial College London, Hammersmith Hospital, Du Cane Road, London W12 0NN, UK
| | - Mara Golemme
- UK Dementia Research Institute Care Research and Technology Centre (UK DRI CR&T) at Imperial College London and the University of Surrey, Imperial College London, White City Campus, 86 Wood Lane, London W12 0BZ, UK; Department of Brain Sciences, Faculty of Medicine, Imperial College London, Hammersmith Hospital, Du Cane Road, London W12 0NN, UK
| | - Claire Norman
- UK Dementia Research Institute Care Research and Technology Centre (UK DRI CR&T) at Imperial College London and the University of Surrey, Imperial College London, White City Campus, 86 Wood Lane, London W12 0BZ, UK; Brook Green Medical Centre, Hammersmith and Fulham GP Partnership, Bute Gardens, London W6 7EG, UK
| | - Kirsten Jensen
- UK Dementia Research Institute Care Research and Technology Centre (UK DRI CR&T) at Imperial College London and the University of Surrey, Imperial College London, White City Campus, 86 Wood Lane, London W12 0BZ, UK; Section of Structural and Synthetic Biology, Department of Infectious Disease, Imperial College London, School of Medicine, St Mary's Hospital, Praed Street, London W2 1NY, UK
| | - Raphaella Jackson
- UK Dementia Research Institute Care Research and Technology Centre (UK DRI CR&T) at Imperial College London and the University of Surrey, Imperial College London, White City Campus, 86 Wood Lane, London W12 0BZ, UK; Section of Structural and Synthetic Biology, Department of Infectious Disease, Imperial College London, School of Medicine, St Mary's Hospital, Praed Street, London W2 1NY, UK
| | - Martin Tran
- UK Dementia Research Institute Care Research and Technology Centre (UK DRI CR&T) at Imperial College London and the University of Surrey, Imperial College London, White City Campus, 86 Wood Lane, London W12 0BZ, UK; Section of Structural and Synthetic Biology, Department of Infectious Disease, Imperial College London, School of Medicine, St Mary's Hospital, Praed Street, London W2 1NY, UK
| | - Paul S Freemont
- UK Dementia Research Institute Care Research and Technology Centre (UK DRI CR&T) at Imperial College London and the University of Surrey, Imperial College London, White City Campus, 86 Wood Lane, London W12 0BZ, UK; Section of Structural and Synthetic Biology, Department of Infectious Disease, Imperial College London, School of Medicine, St Mary's Hospital, Praed Street, London W2 1NY, UK
| | - David Wingfield
- UK Dementia Research Institute Care Research and Technology Centre (UK DRI CR&T) at Imperial College London and the University of Surrey, Imperial College London, White City Campus, 86 Wood Lane, London W12 0BZ, UK; Department of Brain Sciences, Faculty of Medicine, Imperial College London, Hammersmith Hospital, Du Cane Road, London W12 0NN, UK; Brook Green Medical Centre, Hammersmith and Fulham GP Partnership, Bute Gardens, London W6 7EG, UK
| | - Tim Wilkinson
- Centre for Clinical Brain Sciences, University of Edinburgh, 49 Little France Crescent, Edinburgh EH16 4SB, UK
| | - Edward W Gregg
- Department of Epidemiology and Biostatistics, School of Public Health, Imperial College London, South Kensington Campus, London SW7 2AZ, UK; School of Population Health, Royal College of Surgeons of Ireland, University of Medicine and Health Sciences, 123 St Stephen's Green, Dublin 2, Ireland
| | - Ioanna Tzoulaki
- Department of Epidemiology and Biostatistics, School of Public Health, Imperial College London, South Kensington Campus, London SW7 2AZ, UK; Biomedical Research Foundation Academy of Athens, 4 Soranou Ephessiou Street, Athens 115 27, Greece
| | - David J Sharp
- UK Dementia Research Institute Care Research and Technology Centre (UK DRI CR&T) at Imperial College London and the University of Surrey, Imperial College London, White City Campus, 86 Wood Lane, London W12 0BZ, UK; Department of Brain Sciences, Faculty of Medicine, Imperial College London, Hammersmith Hospital, Du Cane Road, London W12 0NN, UK
| | - Eyal Soreq
- UK Dementia Research Institute Care Research and Technology Centre (UK DRI CR&T) at Imperial College London and the University of Surrey, Imperial College London, White City Campus, 86 Wood Lane, London W12 0BZ, UK.
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6
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Patel S, Gill M, Hayward A, Hopkins S, Copas A, Shallcross L. Comparing indicators of disease severity among patients presenting to hospital for urinary tract infections before and during the COVID-19 pandemic. JAC Antimicrob Resist 2024; 6:dlae067. [PMID: 38660368 PMCID: PMC11040270 DOI: 10.1093/jacamr/dlae067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Accepted: 03/26/2024] [Indexed: 04/26/2024] Open
Abstract
Background During the COVID-19 pandemic, patients may have delayed seeking healthcare for urinary tract infections (UTIs). This could have resulted in more severe presentation to hospital and different antibiotic usage. Objectives We explored evidence for such changes through existing national indicators of prescribing, and routine clinical data collected in the electronic health record (EHR). Methods We carried out a retrospective cohort study of patients presenting to two UK hospitals for UTIs, comparing two indicators of disease severity on admission before and during the pandemic: intravenous (IV) antibiotic use, and National Early Warning Score 2 (NEWS2). We developed regression models to estimate the effect of the pandemic on each outcome, adjusting for age, sex, ethnicity and index of multiple deprivation. Results During the pandemic, patients were less likely to present to hospital for UTI with NEWS2 of 0 or 1 [adjusted odds ratio (aOR): 0.66; 95% confidence interval (CI): 0.52-0.85] compared with before, more likely to present with score 2 (aOR: 1.52; 95% CI: 1.18-1.94), whereas the likelihood of presenting with a NEWS2 of >2 remained the same (aOR: 1.06; 95% CI: 0.87-1.29). We did not find evidence that this limited increase in disease severity resulted in changes to IV antibiotic use on admission (adjusted risk ratio: 1.02; 95% CI: 0.91-1.15). Conclusions There may have been a small increase in disease severity at hospital presentation for UTI during the pandemic, which can be detected using routine data and not through national indicators of prescribing. Further research is required to validate these findings and understand whether routine data could support a more nuanced understanding of local antimicrobial prescribing practices.
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Affiliation(s)
- Selina Patel
- Institute of Health Informatics, University College London, London, UK
- UK Health Security Agency, London, UK
| | - Martin Gill
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Andrew Hayward
- Institute of Health Informatics, University College London, London, UK
- UK Health Security Agency, London, UK
| | - Susan Hopkins
- UK Health Security Agency, London, UK
- Division of Infection and Immunity, University College London, London, UK
| | - Andrew Copas
- Institute for Global Health, University College London, London, UK
| | - Laura Shallcross
- Institute of Health Informatics, University College London, London, UK
- UK Health Security Agency, London, UK
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7
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Midby JS, Miesner AR. Delayed and Non-Antibiotic Therapy for Urinary Tract Infections: A Literature Review. J Pharm Pract 2024; 37:212-224. [PMID: 36134708 DOI: 10.1177/08971900221128851] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Urinary tract infections are among the most common infections encountered in the clinic and remain a top indication for women to receive antibiotics. Delayed antibiotic prescribing and non-antibiotic symptomatic therapies are treatment paradigms common to other uncomplicated infectious diseases, such as upper respiratory infections. We aimed to review the literature on delayed antibiotics and non-antibiotic treatments as alternatives to immediate antibiotic prescriptions for uncomplicated cystitis. A literature search was performed in PubMed, Google Scholar, and Web of Science to identify relevant clinical trials and reference lists of included articles were examined to find additional studies. All published trials where same day treatment with antibiotics was compared to scenarios where antibiotics were intentionally delayed or withheld or where antibiotics were compared to non-antimicrobial agents or placebo were analyzed. A total of 13 articles were included. Trials were grouped into categories based on their comparator groups: placebo (n = 5), delayed antibiotic therapy (n = 3), and symptomatic treatment (n = 5). Antibiotic delay and ibuprofen, while less effective than antibiotics in early microbiologic and clinical cure, may still be considered plausible alternatives to immediate antibiotic treatment in non-pregnant women with cystitis. Day 7 and later symptomatic resolution ranges from 26-75% with delayed or placebo therapy and 70-83% with nonsteroidal anti-inflammatory drugs. Symptom improvement, however, may be delayed compared to immediate antibiotics. These approaches have shown to decrease antibiotic use in primary care settings with low rates of pyelonephritis. Methodology included in these studies may be considered in stewardship interventions for outpatient clinics.
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Affiliation(s)
- Jacob S Midby
- Drake University College of Pharmacy & Health Sciences, Des Moines, IA, USA
| | - Andrew R Miesner
- Drake University College of Pharmacy & Health Sciences, Des Moines, IA, USA
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Aryee A, Rockenschaub P, Robson J, Ahmed Z, Nic Fhogartaigh C, Ball D, Hayward A, Shallcross L. Assessing the impact of discordant antibiotic treatment on adverse outcomes in community-onset UTI: a retrospective cohort study. J Antimicrob Chemother 2024; 79:134-142. [PMID: 37974396 PMCID: PMC10761259 DOI: 10.1093/jac/dkad357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Accepted: 11/02/2023] [Indexed: 11/19/2023] Open
Abstract
OBJECTIVES To investigate the risk of adverse outcomes following discordant antibiotic treatment (urinary organism resistant) for culture-confirmed community-onset lower urinary tract infection (UTI). METHODS Cohort study using routinely collected linked primary care, secondary care and microbiology data from patients with culture-confirmed community-onset lower UTI (COLUTI). Antibiotic treatment within ±3 days was considered concordant if the urinary organism was sensitive and discordant if resistant.The primary outcome was the proportion of patients experiencing urinary infection-related hospital admission (UHA) within 30 days. Secondary outcomes were the proportion of patients experiencing reconsultation within 30 days, and the odds of UHA and reconsultation following discordant treatment, adjusting for sex, age, risk factors for complicated UTI, previous antibiotic treatment, recurrent UTI and comorbidities. RESULTS A total of 11 963 UTI episodes in 8324 patients were included, and 1686 episodes (14.1%, 95% CI 13.5%-14.7%) were discordant. UHA occurred in 212/10 277 concordant episodes (2.1%, 95% CI 1.8%-2.4%) and 88/1686 discordant episodes (5.2%, 95% CI 4.2%-6.4%). Reconsultation occurred in 3961 concordant (38.5%, 95% CI 37.6%-39.5%) and 1472 discordant episodes (87.3%, 95% CI 85.6%-88.8%). Discordant treatment compared with concordant was associated with increased odds of UHA (adjusted OR 2.31, 95% CI 1.77-3.0, P < 0.001) and reconsultation (adjusted OR 11.25, 95% CI 9.66-13.11, P < 0.001) on multivariable analysis. Chronic kidney disease and diabetes mellitus were also independently associated with increased odds of UHA. CONCLUSIONS One in seven COLUTI episodes in primary care were treated with discordant antibiotics. In higher risk patients requiring urine culture, empirical antibiotic choice optimization could meaningfully reduce adverse outcomes.
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Affiliation(s)
- Anna Aryee
- Institute of Health Informatics, University College London, 222 Euston Road, London NW1 2DA, UK
| | - Patrick Rockenschaub
- Institute of Health Informatics, University College London, 222 Euston Road, London NW1 2DA, UK
| | - John Robson
- Clinical Effectiveness Group, Queen Mary University of London, Yvonne Carter Building, 58 Turner Street, London E1 2AB, UK
| | - Zaheer Ahmed
- Clinical Effectiveness Group, Queen Mary University of London, Yvonne Carter Building, 58 Turner Street, London E1 2AB, UK
| | - Caoimhe Nic Fhogartaigh
- Department of Microbiology, Barts Health NHS Trust, Pathology and Pharmacy Building, 80 Neward Street, London E1 2ES, UK
| | - David Ball
- Department of Microbiology, Barts Health NHS Trust, Pathology and Pharmacy Building, 80 Neward Street, London E1 2ES, UK
| | - Andrew Hayward
- Institute of Epidemiology and Health Care, University College London, 1-19 Torrington Place, London WC1E 7HB, UK
| | - Laura Shallcross
- Institute of Health Informatics, University College London, 222 Euston Road, London NW1 2DA, UK
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9
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Zou Z, Robinson JI, Steinberg LK, Henderson JP. Uropathogenic Escherichia coli wield enterobactin-derived catabolites as siderophores. J Biol Chem 2024; 300:105554. [PMID: 38072063 PMCID: PMC10788543 DOI: 10.1016/j.jbc.2023.105554] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Revised: 11/20/2023] [Accepted: 12/05/2023] [Indexed: 12/19/2023] Open
Abstract
Uropathogenic Escherichia coli (UPEC) secrete multiple siderophore types to scavenge extracellular iron(III) ions during clinical urinary tract infections, despite the metabolic costs of biosynthesis. Here, we find the siderophore enterobactin (Ent) and its related products to be prominent components of the iron-responsive extracellular metabolome of a model UPEC strain. Using defined Ent biosynthesis and import mutants, we identify lower molecular weight dimeric exometabolites as products of incomplete siderophore catabolism, rather than prematurely released biosynthetic intermediates. In E. coli, iron acquisition from iron(III)-Ent complexes requires intracellular esterases that hydrolyze the siderophore. Although UPEC are equipped to consume the products of completely hydrolyzed Ent, we find that Ent and its derivatives may be incompletely hydrolyzed to yield products with retained siderophore activity. These results are consistent with catabolic inefficiency as means to obtain more than one iron ion per siderophore molecule. This is compatible with an evolved UPEC strategy to maximize the nutritional returns from metabolic investments in siderophore biosynthesis.
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Affiliation(s)
- Zongsen Zou
- Center for Women's Infectious Diseases Research, Washington University School of Medicine, St Louis, Missouri, USA; Division of Infectious Diseases, Department of Internal Medicine, Washington University School of Medicine, St Louis, Missouri, USA
| | - John I Robinson
- Center for Women's Infectious Diseases Research, Washington University School of Medicine, St Louis, Missouri, USA; Division of Infectious Diseases, Department of Internal Medicine, Washington University School of Medicine, St Louis, Missouri, USA
| | - Lindsey K Steinberg
- Center for Women's Infectious Diseases Research, Washington University School of Medicine, St Louis, Missouri, USA; Division of Infectious Diseases, Department of Internal Medicine, Washington University School of Medicine, St Louis, Missouri, USA
| | - Jeffrey P Henderson
- Center for Women's Infectious Diseases Research, Washington University School of Medicine, St Louis, Missouri, USA; Division of Infectious Diseases, Department of Internal Medicine, Washington University School of Medicine, St Louis, Missouri, USA.
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10
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Aryee A, Rockenschaub P, Robson J, Priebe M, Ahmed Z, Fhogartaigh CN, Ball D, Hayward A, Shallcross L. Hospital admission after primary care consultation for community-onset lower urinary tract infection: a cohort study of risks and predictors using linked data. Br J Gen Pract 2023; 73:e694-e701. [PMID: 37487642 PMCID: PMC10394611 DOI: 10.3399/bjgp.2022.0592] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Accepted: 04/05/2023] [Indexed: 07/26/2023] Open
Abstract
BACKGROUND Urinary tract infections (UTIs) are a common indication for antibiotic prescriptions, reductions in which would reduce antimicrobial resistance (AMR). Risk stratification of patients allows reductions to be made safely. AIM To identify risk factors for hospital admission following UTI, to inform targeted antibiotic stewardship. DESIGN AND SETTING Retrospective cohort study of East London primary care patients. METHOD Hospital admission outcomes following primary care consultation for UTI were analysed using linked data from primary care, secondary care, and microbiology, from 1 April 2012 to 31 March 2017. The outcomes analysed were urinary infection-related hospital admission (UHA) and all-cause hospital admission (AHA) within 30 days of UTI in primary care. Odds ratios between specific variables (demographic characteristics, prior antibiotic exposure, and comorbidities) and the outcomes were predicted using generalised estimating equations, and fitted to a final multivariable model including all variables with a P-value <0.1 on univariable analysis. RESULTS Of the 169 524 episodes of UTI, UHA occurred in 1336 cases (0.8%, 95% confidence interval [CI] = 0.7 to 0.8) and AHA in 6516 cases (3.8%, 95% CI = 3.8 to 3.9). On multivariable analysis, increased odds of UHA were seen in patients aged 55-74 years (adjusted odds ratio [AOR] 1.49) and ≥75 years (AOR 3.24), relative to adults aged 16-34 years. Increased odds of UHA were also associated with chronic kidney disease (CKD; AOR 1.55), urinary catheters (AOR 2.01), prior antibiotics (AOR 1.38 for ≥3 courses), recurrent UTI (AOR 1.33), faecal incontinence (FI; AOR 1.47), and diabetes mellitus (DM; AOR 1.37). CONCLUSION Urinary infection-related hospital admission after primary care consultation for community-onset lower UTI was rare; however, increased odds for UHA were observed for some patient groups. Efforts to reduce antibiotic prescribing for suspected UTI should focus on patients aged <55 years without risk factors for complicated UTI, recurrent UTI, DM, or FI.
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Affiliation(s)
- Anna Aryee
- Institute of Health Informatics, University College London, London
| | | | - John Robson
- Clinical Effectiveness Group, Wolfson Institute of Population Health, Queen Mary University of London, London
| | - Marian Priebe
- Clinical Effectiveness Group, Wolfson Institute of Population Health, Queen Mary University of London, London
| | - Zaheer Ahmed
- Clinical Effectiveness Group, Wolfson Institute of Population Health, Queen Mary University of London, London
| | | | | | - Andrew Hayward
- Institute of Epidemiology and Health Care, University College London, London
| | - Laura Shallcross
- Institute of Health Informatics, University College London, London
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11
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Zou Z, Robinson JI, Steinberg LK, Henderson JP. Uropathogenic Escherichia coli wield enterobactin-derived catabolites as siderophores. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2023:2023.07.25.550588. [PMID: 37546885 PMCID: PMC10402112 DOI: 10.1101/2023.07.25.550588] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/08/2023]
Abstract
Uropathogenic E. coli (UPEC) secrete multiple siderophore types to scavenge extracellular iron(III) ions during clinical urinary tract infections, despite the metabolic costs of biosynthesis. Here we find the siderophore enterobactin and its related products to be prominent components of the iron-responsive extracellular metabolome of a model UPEC strain. Using defined enterobactin biosynthesis and import mutants, we identify lower molecular weight, dimeric exometabolites as products of incomplete siderophore catabolism, rather than prematurely released biosynthetic intermediates. In E. coli, iron acquisition from iron(III)-enterobactin complexes requires intracellular esterases that hydrolyze the siderophore. Although UPEC are equipped to consume the products of completely hydrolyzed enterobactin, we find that enterobactin and its derivatives may be incompletely hydrolyzed to yield products with retained siderophore activity. These results are consistent with catabolic inefficiency as means to obtain more than one iron ion per siderophore molecule. This is compatible with an evolved UPEC strategy to maximize the nutritional returns from metabolic investments in siderophore biosynthesis.
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Affiliation(s)
- Zongsen Zou
- Center for Women’s Infectious Diseases Research, Washington University School of Medicine, St. Louis, Missouri, USA
- Department of Internal Medicine, Division of Infectious Diseases, Washington University School of Medicine, St. Louis, Missouri, USA
| | - John I. Robinson
- Center for Women’s Infectious Diseases Research, Washington University School of Medicine, St. Louis, Missouri, USA
- Department of Internal Medicine, Division of Infectious Diseases, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Lindsey K. Steinberg
- Center for Women’s Infectious Diseases Research, Washington University School of Medicine, St. Louis, Missouri, USA
- Department of Internal Medicine, Division of Infectious Diseases, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Jeffrey P. Henderson
- Center for Women’s Infectious Diseases Research, Washington University School of Medicine, St. Louis, Missouri, USA
- Department of Internal Medicine, Division of Infectious Diseases, Washington University School of Medicine, St. Louis, Missouri, USA
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12
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Moragas Moreno A, Fernández-García S, Llor C, Ouchi D, García-Sangenís A, Monteagudo M, Monfà R, Giner-Soriano M. Diagnostic and Therapeutic Management of Urinary Tract Infections in Catalonia, Spain: Protocol for an Observational Cohort Study. JMIR Res Protoc 2023; 12:e44244. [PMID: 36811950 PMCID: PMC9996422 DOI: 10.2196/44244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Revised: 12/19/2022] [Accepted: 12/20/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Antibiotic resistance is an individual and public health problem; multidrug-resistant infections could cause an estimated 10 million deaths worldwide by 2050. Unnecessary use of antimicrobials is the most important cause of resistance generation in the community, and an estimated 80% of antimicrobials are prescribed in primary health care, frequently for urinary tract infections (UTIs). OBJECTIVE This paper presents the protocol for the first phase of the Urinary Tract Infections in Catalonia (Infeccions del tracte urinari a Catalunya) project. We aim to examine the epidemiology of the different types of UTIs in Catalonia (an autonomous community in Spain) and their diagnostic and therapeutic management by health professionals. Furthermore, we aim to evaluate the correlation between types and total consumption of antibiotics for recurrent UTIs in 2 cohorts of women with the presence and severity of infectious complications of urological origin, especially pyelonephritis and sepsis, and 2 potentially serious infections: pneumonia and COVID-19. METHODS The study is a population-based observational cohort study including adults with a diagnosis of UTI registered in the Information System for the Development of Research in Primary Care (in Catalan: Sistema d'informació per al desenvolupament de la investigació en atenció primària), the Minimum Basic Data Sets of Hospital Discharges and Emergency Departments (in Catalan: Conjunt mínim bàsic de dades a l'hospitalització d'aguts i d'atenció urgent), and data from the Hospital Dispensing Medicines Register (in Catalan: Medicació hospitalària de dispensació ambulatòria) of Catalonia from the period between 2012 and 2021. We will evaluate the variables obtained from the databases to analyze the proportion of different types of UTIs, the percentage of adequate antibiotic treatments prescribed or received for recurrent UTIs according to the national guidelines, and the proportion of UTIs with complications. RESULTS We expect to describe the epidemiology of UTIs in Catalonia from 2012 to 2021, as well as describe the diagnostic and therapeutic management of UTIs by health professionals. CONCLUSIONS We expect to find a high percentage of UTI cases with inadequate management according to the national guidelines, considering that on many occasions UTIs are treated with second- or third-line antibiotic therapies with a preference for the longest regimens. Furthermore, the use of antibiotic suppressive therapies, or prophylaxis, in recurrent UTIs will likely be highly variable. Moreover, we aim to determine whether women with recurrent UTIs treated with antibiotic suppressive therapies have a higher incidence and severity of potentially serious future infections, with special attention to acute pyelonephritis, urosepsis, COVID-19, and pneumonia, compared to women who receive antibiotic treatment after they present with a UTI. This is an observational study of data from administrative databases that will not allow causality analysis. The limitations of the study will be handled according to the appropriate statistical methods. TRIAL REGISTRATION European Union Electronic Register of Post-Authorisation Studies EUPAS49724; https://www.encepp.eu/encepp/viewResource.htm?id=49725. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/44244.
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Affiliation(s)
- Ana Moragas Moreno
- Institut Català de la Salut, Centre d'Atenció Primària Jaume I, Tarragona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Infecciosas, Instituto Carlos III, Madrid, Spain.,Universitat Rovira i Virgili, Reus, Spain
| | - Silvia Fernández-García
- Fundació Institut Universitari per a la Recerca a l'Atenció Primària de Salut Jordi Gol i Gurina, Barcelona, Spain.,Universitat de Girona, Girona, Spain.,Universitat Autònoma de Barcelona, Bellaterra (Cerdanyola del Vallès), Spain
| | - Carl Llor
- Centro de Investigación Biomédica en Red de Enfermedades Infecciosas, Instituto Carlos III, Madrid, Spain.,Fundació Institut Universitari per a la Recerca a l'Atenció Primària de Salut Jordi Gol i Gurina, Barcelona, Spain.,Research Unit for General Practice, Department of Public Health, University of Southern Denmark, Odense, Denmark
| | - Dan Ouchi
- Fundació Institut Universitari per a la Recerca a l'Atenció Primària de Salut Jordi Gol i Gurina, Barcelona, Spain.,Universitat Autònoma de Barcelona, Bellaterra (Cerdanyola del Vallès), Spain
| | - Ana García-Sangenís
- Centro de Investigación Biomédica en Red de Enfermedades Infecciosas, Instituto Carlos III, Madrid, Spain.,Fundació Institut Universitari per a la Recerca a l'Atenció Primària de Salut Jordi Gol i Gurina, Barcelona, Spain
| | - Mònica Monteagudo
- Fundació Institut Universitari per a la Recerca a l'Atenció Primària de Salut Jordi Gol i Gurina, Barcelona, Spain.,Universitat Autònoma de Barcelona, Bellaterra (Cerdanyola del Vallès), Spain
| | - Ramon Monfà
- Fundació Institut Universitari per a la Recerca a l'Atenció Primària de Salut Jordi Gol i Gurina, Barcelona, Spain.,Universitat Autònoma de Barcelona, Bellaterra (Cerdanyola del Vallès), Spain.,Spanish Clinical Research Network, Clinical Research Unit Fundació Institut Universitari per a la Recerca a l'Atenció Primària de Salut Jordi Gol i Gurina, Barcelona, Spain
| | - Maria Giner-Soriano
- Fundació Institut Universitari per a la Recerca a l'Atenció Primària de Salut Jordi Gol i Gurina, Barcelona, Spain.,Universitat Autònoma de Barcelona, Bellaterra (Cerdanyola del Vallès), Spain
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13
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Salem MR, Youssef MRL, Shalaby SF, Mahmoud AT, Ismail M, Ibrahim SK. Perspectives on Antibiotic Stewardship Programs among Health Care Providers at Two University Hospitals in Egypt. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:3777. [PMID: 36900787 PMCID: PMC10001175 DOI: 10.3390/ijerph20053777] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Revised: 02/02/2023] [Accepted: 02/08/2023] [Indexed: 06/18/2023]
Abstract
The perspectives of healthcare professionals on antibiotic stewardship programs (ASPs) should be explored. Any antibiotic stewardship strategy must be individualized based on patient needs, prescription habits, and local resources. The current study aimed to explore the perspectives of healthcare providers on antibiotics stewardship and their awareness of these perspectives. Furthermore, potential barriers to the application of ASPs should be identified and addressed. This exploratory cross-sectional study utilized a qualitative method to evaluate critical care physicians, pediatricians, and clinical pharmacists (n = 43). The mean age of the physicians was 32 ± 1.5 years. Among them, approximately two-thirds (66%) were women. A thematic content analysis was performed to examine the responses of the participants and to prioritize the recommendations for and barriers to the implementation of ASPs from the perspective of healthcare providers. According to the interviewees, the primary obstacles include lack of time in implementation and monitoring and lack of awareness of the need for ASPs. All respondents recommended the implementation of supervised and continuous trainings. In conclusion, the abovementioned barriers must be adequately addressed to facilitate the implementation of ASPs.
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Affiliation(s)
- Marwa Rashad Salem
- Department of Public Health and Community Medicine, Faculty of Medicine, Cairo University, Manial, Cairo 11559, Egypt
| | | | - Silvia Farouk Shalaby
- Department of Public Health and Community Medicine, Faculty of Medicine, Cairo University, Manial, Cairo 11559, Egypt
| | - Ahmed Taher Mahmoud
- Department of Critical Care Medicine, Faculty of Medicine, Cairo University, Manial, Cairo 11559, Egypt
| | - Mohamed Ismail
- Department of Pediatrics, Faculty of Medicine, Cairo University, Manial, Cairo 11559, Egypt
| | - Sally Kamal Ibrahim
- Department of Pediatrics, Faculty of Medicine, Cairo University, Manial, Cairo 11559, Egypt
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14
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Lodise TP, Nowak M, Rodriguez M. The 30-Day Economic Burden of Newly Diagnosed Complicated Urinary Tract Infections in Medicare Fee-for-Service Patients Who Resided in the Community. Antibiotics (Basel) 2022; 11:antibiotics11050578. [PMID: 35625222 PMCID: PMC9137853 DOI: 10.3390/antibiotics11050578] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Revised: 04/20/2022] [Accepted: 04/20/2022] [Indexed: 02/05/2023] Open
Abstract
Introduction: Scant data are available on the 30-day financial burden associated with incident complicated urinary tract infections (cUTIs) in a cohort of predominately elderly patients. This study sought to examine total and cUTI-related 30-day Medicare spending (MS), a proxy for healthcare costs, among Medicare fee-for-service (FFS) beneficiaries who resided in the community with newly diagnosed cUTIs. Methods: A retrospective multicenter cohort study of adult beneficiaries in the Medicare FFS database with a cUTI between 2017 and 2018 was performed. Patients were included if they were enrolled in Medicare FFS and Medicare Part D from 2016 to 2019, had a cUTI first diagnosis in 2017–2018, no evidence of any UTI diagnoses in 2016, and residence in the community between 2016 and 2018. Results: During the study period, 723,324 cases occurred in Medicare beneficiaries who met the study criteria. Overall and cUTI-related 30-day MS were $7.6 and $4.5 billion, respectively. The average overall and cUTI-related 30-day MS per beneficiary were $10,527 and $6181, respectively. The major driver of cUTI-related 30-day MS was acute care hospitalizations ($3.2 billion) and the average overall and cUTI-related 30-day MS per hospitalizations were $16,431 and $15,438, respectively. Conclusion: Overall 30-day MS for Medicare FSS patients who resided in the community with incident cUTIs was substantial, with cUTI-related MS accounting for 59%. As the major driver of cUTI-related 30-day MS was acute care hospitalizations, healthcare systems should develop well-defined criteria for hospital admissions that aim to avert hospitalizations in clinically stable patients and expedite the transition of patients to the outpatient setting to complete their care.
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Affiliation(s)
- Thomas P. Lodise
- Albany College of Pharmacy and Health Sciences, Albany, NY 12208, USA
- Correspondence: ; Tel.: +1-518-694-7292
| | - Michael Nowak
- Spero Therapeutics, Inc., Cambridge, MA 02139, USA; (M.N.); (M.R.)
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15
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Vendeville JB, Kyriakides MJ, Takebayashi Y, Rama S, Preece J, Samphire J, Ramos-Soriano J, Amieva AM, Holbrow-Wilshaw ME, Gordon Newman HR, Kou SL, Medina-Villar S, Dorh N, Dorh JN, Spencer J, Galan MC. Fast Identification and Quantification of Uropathogenic E. coli through Cluster Analysis. ACS Biomater Sci Eng 2021; 8:242-252. [PMID: 34894660 DOI: 10.1021/acsbiomaterials.1c00732] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Rapid diagnostic tools to detect, identify, and enumerate bacteria are key to maintaining effective antibiotic stewardship and avoiding the unnecessary prescription of broad-spectrum agents. In this study, a 15 min agglutination assay is developed that relies on the use of mannose-functionalized polymeric microspheres in combination with cluster analysis. This allows for the identification and enumeration of laboratory (BW25113), clinical isolate (NCTC 12241), and uropathogenic Escherichia coli strains (NCTC 9001, NCTC 13958, J96, and CFT073) at clinically relevant concentrations in tryptic soy broth (103-108 CFU/mL) and in urine (105-108 CFU/mL). This fast, simple, and efficient assay offers a step forward toward efficient point-of-care diagnostics for common urinary tract infections.
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Affiliation(s)
| | | | - Yuiko Takebayashi
- School of Cellular and Molecular Medicine, University of Bristol, University Walk, BS8 1TD Bristol, United Kingdom
| | - Sylvain Rama
- FluoretiQ, Unit DX, St Philips Central, Albert Road, BS2 0XJ Bristol, United Kingdom
| | - James Preece
- FluoretiQ, Unit DX, St Philips Central, Albert Road, BS2 0XJ Bristol, United Kingdom
| | - Jenny Samphire
- School of Chemistry, University of Bristol, Cantock''s Close, BS8 1TS Bristol, United Kingdom
| | - Javier Ramos-Soriano
- School of Chemistry, University of Bristol, Cantock''s Close, BS8 1TS Bristol, United Kingdom
| | | | | | | | - Sio Lou Kou
- FluoretiQ, Unit DX, St Philips Central, Albert Road, BS2 0XJ Bristol, United Kingdom
| | - Sandra Medina-Villar
- FluoretiQ, Unit DX, St Philips Central, Albert Road, BS2 0XJ Bristol, United Kingdom
| | - Neciah Dorh
- FluoretiQ, Unit DX, St Philips Central, Albert Road, BS2 0XJ Bristol, United Kingdom
| | - Josephine Ndoa Dorh
- FluoretiQ, Unit DX, St Philips Central, Albert Road, BS2 0XJ Bristol, United Kingdom
| | - James Spencer
- School of Cellular and Molecular Medicine, University of Bristol, University Walk, BS8 1TD Bristol, United Kingdom
| | - M Carmen Galan
- School of Chemistry, University of Bristol, Cantock''s Close, BS8 1TS Bristol, United Kingdom
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16
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Jin L, Zhao C, Li H, Wang R, Wang Q, Wang H. Clinical Profile, Prognostic Factors, and Outcome Prediction in Hospitalized Patients With Bloodstream Infection: Results From a 10-Year Prospective Multicenter Study. Front Med (Lausanne) 2021; 8:629671. [PMID: 34095163 PMCID: PMC8172964 DOI: 10.3389/fmed.2021.629671] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2020] [Accepted: 03/15/2021] [Indexed: 12/23/2022] Open
Abstract
Background: Bloodstream infection (BSI) is one of the most common serious bacterial infections worldwide and also a major contributor to in-hospital mortality. Determining the predictors of mortality is crucial for prevention and improving clinical prognosis in patients with nosocomial BSI. Methods: A nationwide prospective cohort study was conducted from 2007 until 2016 in 16 teaching hospitals across China. Microbiological results, clinical information, and patient outcomes were collected to investigate the pathogenic spectrum and mortality rate in patients with BSI and identify outcome predictors using multivariate regression, prediction model, and Kaplan-Meier analysis. Results: No significant change was observed in the causative pathogen distribution during the 10-year period and the overall in-hospital mortality was 12.83% (480/3,741). An increased trend was found in the mortality of patients infected with Pseudomonas aeruginosa or Acinetobacter baumannii, while a decreased mortality rate was noted in Staphylococcus aureus-related BSI. In multivariable-adjusted models, higher mortality rate was significantly associated with older age, cancer, sepsis diagnosis, ICU admission, and prolonged hospital stay prior to BSI onset, which were also determined using machine learning-based predictive model achieved by random forest algorithm with a satisfactory performance in outcome prediction. Conclusions: Our study described the clinical and microbiological characteristics and mortality predictive factors in patients with BSI. These informative predictors would inform clinical practice to adopt effective therapeutic strategies to improve patient outcomes.
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Affiliation(s)
- Longyang Jin
- Department of Clinical Laboratory, Peking University People's Hospital, Beijing, China
| | - Chunjiang Zhao
- Department of Clinical Laboratory, Peking University People's Hospital, Beijing, China
| | - Henan Li
- Department of Clinical Laboratory, Peking University People's Hospital, Beijing, China
| | - Ruobing Wang
- Department of Clinical Laboratory, Peking University People's Hospital, Beijing, China
| | - Qi Wang
- Department of Clinical Laboratory, Peking University People's Hospital, Beijing, China
| | - Hui Wang
- Department of Clinical Laboratory, Peking University People's Hospital, Beijing, China
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17
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Rezel-Potts E, L'Esperance V, Gulliford MC. Antimicrobial stewardship in the UK during the COVID-19 pandemic: a population-based cohort study and interrupted time-series analysis. Br J Gen Pract 2021; 71:e331-e338. [PMID: 33690150 PMCID: PMC8049219 DOI: 10.3399/bjgp.2020.1051] [Citation(s) in RCA: 38] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Accepted: 02/22/2021] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND The COVID-19 pandemic has altered the context for antimicrobial stewardship in primary care. AIM To assess the effect of the pandemic on antibiotic prescribing, accounting for changes in consultations for respiratory and urinary tract infections (RTIs/UTIs). DESIGN AND SETTING Population-based cohort study using the UK Clinical Practice Research Datalink (CPRD) GOLD database from January 2017 to September 2020. METHOD Interrupted time-series analysis evaluated changes in antibiotic prescribing and RTI/UTI consultations adjusting for age, sex, season, and secular trends. The authors assessed the proportion of COVID-19 episodes associated with antibiotic prescribing. RESULTS There were 253 655 registered patients in 2017 and 232 218 in 2020, with 559 461 antibiotic prescriptions, 216 110 RTI consultations, and 36 402 UTI consultations. Compared with prepandemic months, March 2020 was associated with higher antibiotic prescribing (adjusted rate ratio [ARR] 1.13; 95% confidence interval [CI] = 1.11 to 1.16). Antibiotic prescribing fell below predicted rates between April and August 2020, reaching a minimum in May (ARR 0.73; 95% CI = 0.71 to 0.75). Pandemic months were associated with lower rates of RTI/UTI consultations, particularly in April for RTIs (ARR 0.23; 95% CI = 0.22 to 0.25). There were small reductions in the proportion of RTI consultations with antibiotic prescribed and no reduction for UTIs. Among 25 889 COVID-19 patients, 2942 (11%) had antibiotics within a COVID-19 episode. CONCLUSION Pandemic months were initially associated with increased antibiotic prescribing, which then fell below expected levels during the national lockdown. Findings are reassuring that antibiotic stewardship priorities have not been neglected because of COVID-19. Research is required into the effects of reduced RTI/UTI consultations on incidence of serious bacterial infections.
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Affiliation(s)
- Emma Rezel-Potts
- School of Population Health and Environmental Sciences, King's College London, London; National Institute for Health Research Biomedical Research Centre (BRC), Guy's and St Thomas' NHS Foundation Trust, London
| | - Veline L'Esperance
- School of Population Health and Environmental Sciences, King's College London, London
| | - Martin C Gulliford
- School of Population Health and Environmental Sciences, King's College London; National Institute for Health Research (NIHR) Biomedical Research Centre (BRC), Guy's and St Thomas' NHS Foundation Trust, London
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18
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Thematic research clusters in very old populations (≥ 80 years): a bibliometric approach. BMC Geriatr 2021; 21:266. [PMID: 33882849 PMCID: PMC8058755 DOI: 10.1186/s12877-021-02209-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Accepted: 03/25/2021] [Indexed: 12/17/2022] Open
Abstract
Background Population aging will be one of humanity’s major challenges in the decades to come. In addition to focusing on the pathologies causing the greatest mortality and morbidity in this population, such as dementia, health research in elderly people must consider a myriad of other interlinked factors, such as geriatric syndromes, social aspects, and factors related to preserving quality of life and promoting healthy aging. This study aims to identify the main subject areas attracting research attention with regard to very old (≥ 80 years) populations. Methods Documents assigned with the medical subject heading “Aged, 80 and over” were retrieved from MEDLINE and the Web of Science. This dataset was used to determine publication output by disease, geographic region, country, and discipline. A co-word analysis was undertaken to identify thematic research clusters. Results Since the mid-2000s, there has been a boom in scientific output focusing specifically on very old populations, especially in Europe (43.7% of the documents) but also in North America (30.5%) and Asia (26%); other regions made only nominal contributions (0.5 to 4.4%). The USA produced the most research, while the most growth over the study period occurred in Japan, Spain, and China. Four broad thematic clusters were identified: a) geriatric diseases, health services for the aged, and social and psychological issues of aging; b) cardiovascular diseases; c) neoplasms, and d) bacterial infections & anti-bacterial agents. Conclusions Scientific research in very old populations covers a wide variety of interrelated topics. In quantitative terms, the top subject areas have to do with cardiovascular and cerebrovascular diseases (including aortic valve stenosis and stroke), dementia, and neoplasms. However, other degenerative pathologies, geriatric syndromes, and different social and psychosocial aspects also attract considerable interest. It is necessary to promote more equal participation in global research on pathologies and topics related to very elderly populations, as the highest rates of population aging and the largest numbers of elderly people in the next decades will be in low- and middle-income countries. Supplementary Information The online version contains supplementary material available at 10.1186/s12877-021-02209-7.
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19
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Lichtinger U, Greifenberg V, Gessner A. [Antibiotic stewardship (ABS)-strategies for urologists in private practice and hospitals]. Urologe A 2020; 59:1472-1479. [PMID: 33201296 PMCID: PMC7721682 DOI: 10.1007/s00120-020-01385-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Antibiotika sind wirksame und sichere Arzneimittel und haben seit ihrer Einführung Millionen von Menschenleben gerettet. Die Weltgesundheitsorganisation (WHO) hat die weltweit zunehmenden Antibiotikaresistenzen als eines der größten Gesundheitsprobleme der Gegenwart identifiziert. Zu den häufigsten Indikationen für eine Antibiotikatherapie gehören Harnwegsinfektionen, bei denen nach aktuellen Erfassungen in einem sehr hohen Prozentsatz allerdings nicht leitliniengerecht behandelt wird. Um die fortlaufende Selektion von resistenten Bakterien, und unerwünschte oder sogar gefährliche Nebenwirkungen wie z. B. durch Schädigungen des Mikrobioms der Patienten zu vermeiden, sind dringend Strategien zur Verbesserung der Antibiotikatherapie durch „antibiotic stewardship“ (ABS) erforderlich. Insbesondere für Urologen in der ambulanten Patientenversorgung bedarf es hierfür neuer, innovativer und nachhaltiger Schulungskonzepte, die Wissen kontinuierlich aktuell halten und sachgerechte Antibiotikaverschreibungen nachhaltig unterstützen.
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Affiliation(s)
- U Lichtinger
- Pädagogische Hochschule Vorarlberg, Feldkirch, Österreich
| | - V Greifenberg
- Institut für Klinische Mikrobiologie und Hygiene, Universitätsklinikum Regensburg, Franz-Josef-Strauss Allee 11, 93053, Regensburg, Deutschland
| | - A Gessner
- Institut für Klinische Mikrobiologie und Hygiene, Universitätsklinikum Regensburg, Franz-Josef-Strauss Allee 11, 93053, Regensburg, Deutschland.
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