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Kurotschka PK, Hemkeppler J, Gierszewski D, Ghirotto L, Gágyor I. General practitioners' decision making managing uncomplicated urinary tract infections in women: a qualitative study. BJGP Open 2024:BJGPO.2023.0224. [PMID: 38423622 DOI: 10.3399/bjgpo.2023.0224] [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: 11/06/2023] [Revised: 01/03/2024] [Accepted: 02/07/2024] [Indexed: 03/02/2024] Open
Abstract
BACKGROUND To be effective, interventions aimed at increasing the appropriateness of antibiotic use in primary care should consider the perspectives of prescribing physicians. AIM To explore the decision making of general practitioners (GPs) when managing uncomplicated urinary tract infections (uUTIs) in women. DESIGN & SETTING A qualitative study using semi-structured interviews with 22 GPs in Bavaria and Baden-Württemberg (southern Germany). METHOD Verbatim transcripts were analysed through inductive qualitative content analysis. RESULTS We generated the following three main themes: factors facilitating the decision making; factors complicating the decision making; and consultation modalities. According to participants, following evidence-based recommendations makes the prescription decision smoother. GPs' and patients' prior experiences and beliefs guides decisions towards certain antibiotics, even if those experiences and beliefs contradict evidence-based recommendations. Patient expectations and demands also condition antibiotic prescribing, favouring it. Organisational constraints, such as time pressure, the day of the week (for example, before weekends), and a lower cost of antibiotics for patients than alternative treatments favour the decision to prescribe antibiotics. Diagnostic and prognostic uncertainty complicates decision making, as does scepticism towards evidence-based recommendations. Discordance within the patient-doctor relationship contributed to this complexity. Regarding consultation modalities, a more in-depth consultation and shared decision making were seen as helpful in this process. CONCLUSION We identified different factors as intervening against or for a straightforward management decision when dealing with women with uUTIs. They reveal the complexity behind the GPs' decision making. Providing GPs with easy-to-apply guidance while removing economic constraints to allocate sufficient consultation time, and supporting shared decision making may help GPs appropriately manage uUTIs in women.
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Affiliation(s)
- Peter K Kurotschka
- Department of General Practice, University Hospital Wurzburg, Wurzburg, Germany
| | - Juliane Hemkeppler
- Department of General Practice, University Hospital Wurzburg, Wurzburg, Germany
| | - David Gierszewski
- Department of General Practice, University Hospital Wurzburg, Wurzburg, Germany
| | - Luca Ghirotto
- Qualitative Research Unit, Azienda USL - IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Ildikó Gágyor
- Department of General Practice, University Hospital Wurzburg, Wurzburg, Germany
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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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Frimodt-Møller N, Bjerrum L. Treating urinary tract infections in the era of antibiotic resistance. Expert Rev Anti Infect Ther 2023; 21:1301-1308. [PMID: 37922147 DOI: 10.1080/14787210.2023.2279104] [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: 06/21/2023] [Accepted: 10/31/2023] [Indexed: 11/05/2023]
Abstract
INTRODUCTION Urinary tract infections (UTIs) are associated with 25-40% of antibiotics consumed in primary care and are, therefore, driving antibiotic resistance. The worldwide increase in antibiotic resistance especially in Escherichia coli has complicated the treatment choices for UTIs and absence of effective oral antibiotics may lead to increasing need for more effective treatments. AREAS COVERED In this review we focus on the importance of the correct diagnosis of UTI as based on proof of urinary pathogens in the urine and discuss diagnostic measures including microscopy, dipstick, and culture. Antibiotic treatment can often await diagnostic measures with pain relief such as ibuprofen. The risk of an uncomplicated UTI leading to pyelonephritis is low (1-2%) and presence of bacteria in the bladder leaves some time for the immune system to react. Three antibiotics are recommended as based on their activity, and low propensity to select for resistance, i.e. nitrofurantoin, fosfomycin, and pivmecillinam, and in general, 3-5 days of treatment will suffice. EXPERT OPINION Understanding the usual benign course of uUTIs can help reduce antibiotic treatment in many cases, e.g. starting treatment by pain relief and awaiting the course of infection without antibiotics. Better rapid tests in primary care are urgently needed to enforce such policies.
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Affiliation(s)
| | - Lars Bjerrum
- Research Unit and Section of General Practice, Dept of Public Health, University of Copenhagen, Copenhagen, Denmark
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Seheult JN, Stram MN, Contis L, Pontzer RE, Hardy S, Wertz W, Baxter CM, Ondras M, Kip PL, Snyder GM, Pasculle AW. Development, Evaluation, and Multisite Deployment of a Machine Learning Decision Tree Algorithm To Optimize Urinalysis Parameters for Predicting Urine Culture Positivity. J Clin Microbiol 2023; 61:e0029123. [PMID: 37227272 PMCID: PMC10281150 DOI: 10.1128/jcm.00291-23] [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: 03/14/2023] [Accepted: 04/21/2023] [Indexed: 05/26/2023] Open
Abstract
PittUDT, a recursive partitioning decision tree algorithm for predicting urine culture (UC) positivity based on macroscopic and microscopic urinalysis (UA) parameters, was developed in support of a broader system-wide diagnostic stewardship initiative to increase appropriateness of UC testing. Reflex algorithm training utilized results from 19,511 paired UA and UC cases (26.8% UC positive); the average patient age was 57.4 years, and 70% of samples were from female patients. Receiver operating characteristic (ROC) analysis identified urine white blood cells (WBCs), leukocyte esterase, and bacteria as the best predictors of UC positivity, with areas under the ROC curve of 0.79, 0.78, and 0.77, respectively. Using the held-out test data set (9,773 cases; 26.3% UC positive), the PittUDT algorithm met the prespecified target of a negative predictive value above 90% and resulted in a 30 to 60% total negative proportion (true-negative plus false-negative predictions). These data show that a supervised rule-based machine learning algorithm trained on paired UA and UC data has adequate predictive ability for triaging urine specimens by identifying low-risk urine specimens, which are unlikely to grow pathogenic organisms, with a false-negative proportion under 5%. The decision tree approach also generates human-readable rules that can be easily implemented across multiple hospital sites and settings. Our work demonstrates how a data-driven approach can be used to optimize UA parameters for predicting UC positivity in a reflex protocol, with the intent of improving antimicrobial stewardship and UC utilization, a potential avenue for cost savings.
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Affiliation(s)
- Jansen N. Seheult
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Michelle N. Stram
- Department of Forensic Medicine, NYU Langone Health, New York, New York, USA
| | - Lydia Contis
- Department of Pathology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Raymond E. Pontzer
- Infection Control and Hospital Epidemiology, UPMC, Pittsburgh, Pennsylvania, USA
| | - Stephanie Hardy
- Laboratory Service Center, UPMC, Pittsburgh, Pennsylvania, USA
| | - William Wertz
- Laboratory Service Center, UPMC, Pittsburgh, Pennsylvania, USA
| | | | - Michael Ondras
- Laboratory Service Center, UPMC, Pittsburgh, Pennsylvania, USA
| | - Paula L. Kip
- Wolff Center, UPMC, Pittsburgh, Pennsylvania, USA
| | - Graham M. Snyder
- Infection Control and Hospital Epidemiology, UPMC, Pittsburgh, Pennsylvania, USA
- Division of Infectious Diseases, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - A. William Pasculle
- Department of Pathology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Clinical Microbiology Laboratory, UPMC, Pittsburgh, Pennsylvania, USA
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5
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de Vries S, Ten Doesschate T, Totté JEE, Heutz JW, Loeffen YGT, Oosterheert JJ, Thierens D, Boel E. A semi-supervised decision support system to facilitate antibiotic stewardship for urinary tract infections. Comput Biol Med 2022; 146:105621. [PMID: 35617725 DOI: 10.1016/j.compbiomed.2022.105621] [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: 12/31/2021] [Revised: 02/18/2022] [Accepted: 03/19/2022] [Indexed: 11/15/2022]
Abstract
Urinary Tract Infections (UTIs) are among the most frequently occurring infections in the hospital. Urinalysis and urine culture are the main tools used for diagnosis. Whereas urinalysis is sufficiently sensitive for detecting UTI, it has a relatively low specificity, leading to unnecessary treatment with antibiotics and the risk of increasing antibiotic resistance. We performed an evaluation of the current diagnostic process with an expert-based label for UTI as outcome, retrospectively established using data from the Electronic Health Records. We found that the combination of urinalysis results with the Gram stain and other readily available parameters can be used effectively for predicting UTI. Based on the obtained information, we engineered a clinical decision support system (CDSS) using the reliable semi-supervised ensemble learning (RESSEL) method, and found it to be more accurate than urinalysis or the urine culture for prediction of UTI. The CDSS provides clinicians with this prediction within hours of ordering a culture and thereby enables them to hold off on prematurely prescribing antibiotics for UTI while awaiting the culture results.
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Affiliation(s)
- Sjoerd de Vries
- Department of Information and Computing Sciences, Utrecht University, Princetonplein 5, 3584 CC, Utrecht, the Netherlands; Department of Digital Health, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, the Netherlands.
| | - Thijs Ten Doesschate
- Department of Internal Medicine, Infectious Diseases, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, the Netherlands
| | - Joan E E Totté
- Department of Medical Microbiology, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, the Netherlands
| | - Judith W Heutz
- Department of Medical Microbiology, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, the Netherlands; Department of Rheumatology, Erasmus Medical Center, Dr. Molewaterplein 40, 3015 GD, Rotterdam, the Netherlands
| | - Yvette G T Loeffen
- Division of Pediatric Immunology and Infectious Diseases, Wilhelmina Children's Hospital Utrecht, Lundlaan 6, 3584 EA, Utrecht, the Netherlands
| | - Jan Jelrik Oosterheert
- Department of Internal Medicine, Infectious Diseases, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, the Netherlands
| | - Dirk Thierens
- Department of Information and Computing Sciences, Utrecht University, Princetonplein 5, 3584 CC, Utrecht, the Netherlands
| | - Edwin Boel
- Department of Medical Microbiology, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, the Netherlands
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Kaußner Y, Röver C, Heinz J, Hummers E, Debray TPA, Hay AD, Heytens S, Vik I, Little P, Moore M, Stuart B, Wagenlehner F, Kronenberg A, Ferry S, Monsen T, Lindbæk M, Friede T, Gágyor I. Reducing antibiotic use in uncomplicated urinary tract infections in adult women: a systematic review and individual participant data meta-analysis. Clin Microbiol Infect 2022; 28:1558-1566. [PMID: 35788049 DOI: 10.1016/j.cmi.2022.06.017] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Revised: 06/13/2022] [Accepted: 06/14/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Randomised controlled trials (RCTs) investigated analgesics, herbal formulations, delayed prescription of antibiotics and placebo to prevent overprescription of antibiotics in women with uncomplicated urinary tract infections (uUTI). OBJECTIVES To estimate the effect of these strategies and to identify symptoms, signs or other factors that indicate a benefit from these strategies. DATA SOURCES MEDLINE, EMBASE, Web of Science, LILACS, Cochrane Database of Systematic Reviews and of Controlled Trials, and ClinicalTrials. STUDY ELIGIBILITY CRITERIA, PARTICIPANTS AND INTERVENTIONS RCTs investigating any strategies to reduce antibiotics versus immediate antibiotics in adult women with uUTI in primary care. DATA SYNTHESIS We extracted individual participant data (IPD) if available, otherwise aggregate data (AD). Bayesian random-effects meta-analysis of the AD was used for pairwise comparisons. Candidate moderators and prognostic indicators of treatment effects were investigated using generalised linear mixed models based on IPD. RESULTS We analysed IPD of 3524 patients from eight RCTs and AD of 78 patients. Non-antibiotic strategies increased the rates of incomplete recovery (odds ratio [OR] 3.0; 95% credible interval [CI] 1.7-5.5; Bayesian p-value pB=0.0017; τ=0.6), subsequent antibiotic treatment (OR 3.5 [95% CI 2.1, 5.8; pB=0.0003) and pyelonephritis (OR 5.6; 95% CI 2.3, 13.9; pB=0.0003). Conversely, they decreased overall antibiotic use by 63%. In patients positive for urinary erythrocytes and urine culture were at increased risk for incomplete recovery (OR 4.7; 95% CI 2.1-10.8; pB =0.0010), but no difference was apparent where both were negative (OR 0.8; 95% CI 0.3-2.0; pB =0.667). In patients treated with using non-antibiotic strategies, urinary erythrocytes and positive urine culture were independent prognostic indicators for subsequent antibiotic treatment and pyelonephritis. CONCLUSIONS AND RELEVANCE Compared to immediate antibiotics, non-antibiotic strategies reduce overall antibiotic use but result in poorer clinical outcomes. The presence of erythrocytes and tests to confirm bacteria in urine could be used to target antibiotic prescribing.
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Affiliation(s)
- Yvonne Kaußner
- Department of General Practice, University Medical Center Wuerzburg, Germany.
| | - Christian Röver
- Department of Medical Statistics, University Medical Center Goettingen, Germany.
| | - Judith Heinz
- Department of Medical Statistics, University Medical Center Goettingen, Germany.
| | - Eva Hummers
- Department of General Practice, University Medical Center Goettingen, Germany.
| | - Thomas P A Debray
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, the Netherlands.
| | - Alastair D Hay
- Centre for Academic Primary Care, Bristol Medical School: Population Health Sciences, Bristol BS8 2PS.
| | - Stefan Heytens
- Department of Public Health and Primary Care, University of Ghent, Belgium.
| | - Ingvild Vik
- Antibiotic Centre of Primary Care, Department of General Practice, Institute of Health and Society, University of Oslo, Norway; Department of Emergency General Practice, Oslo Accident and Emergency Outpatient Clinic, Norway.
| | - Paul Little
- Primary Care Research Centre, School of Primary Care Population Sciences and Medical Education Unit, Faculty of Medicine, University of Southampton, Aldermoor Health Centre, UK.
| | - Michael Moore
- Primary Care Research Centre, School of Primary Care Population Sciences and Medical Education Unit, Faculty of Medicine, University of Southampton, Aldermoor Health Centre, UK.
| | - Beth Stuart
- Primary Care Research Centre, School of Primary Care Population Sciences and Medical Education Unit, Faculty of Medicine, University of Southampton, Aldermoor Health Centre, UK.
| | - Florian Wagenlehner
- Clinic for Urology, Pediatric Urology and Andrology, Justus Liebig University Giessen, Germany.
| | - Andreas Kronenberg
- Institute for Infectious Diseases, University of Bern, Bern, Switzerland.
| | - Sven Ferry
- Department of Clinical Microbiology, Umeå University, Sweden.
| | - Tor Monsen
- Department of Clinical Microbiology, Umeå University, Sweden.
| | - Morten Lindbæk
- Antibiotic Centre of Primary Care, Department of General Practice, Institute of Health and Society, University of Oslo, Norway.
| | - Tim Friede
- Department of Medical Statistics, University Medical Center Goettingen, Germany.
| | - Ildikó Gágyor
- Department of General Practice, University Medical Center Wuerzburg, Germany; Department of General Practice, University Medical Center Goettingen, Germany.
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7
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Kollerup I, Aagaard Thomsen AK, Kornum JB, Paulsen KI, Bjerrum L, Hansen MP. Use and quality of point-of-care microscopy, urine culture and susceptibility testing for urinalysis in general practice. Scand J Prim Health Care 2022; 40:3-10. [PMID: 35023809 PMCID: PMC9090341 DOI: 10.1080/02813432.2021.2022349] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Accepted: 11/12/2021] [Indexed: 11/05/2022] Open
Abstract
Objective: To describe the use and quality of point-of-care (POC) microscopy, urine culture and susceptibility testing performed in general practice in Northern Denmark from 2013 to 2018.Design: Descriptive studySetting: General practices receiving a fee for examining urine samples.Subjects: Simulated urine samples containing uropathogenic bacteria distributed by the organisation for improvement of microbiological quality (MIKAP).Main outcome measures: Percentage of use and correct answers for microscopy, culture and susceptibility testing.Results: A total of 5361 samples were analysed by the use of microscopy (39.7%), culture (66.0%) and/or susceptibility testing (76.5%). For culture, Flexicult SSI urinary kittm (87.6%) demonstrated the highest percentage of correct answers followed by chromogenic agar (85.1%) and 2-plate dipslide (85.2%). Mueller Hinton agar with tablets had the highest percentage of correct answers for susceptibility testing of most bacterial strains (84.6%), followed by Flexicult (77.2%). Furthermore, susceptibility testing with tablets (range: 76.1-84.6%) was found to be more accurate than discs (range: 72.9-75.5%). Overall, the highest percentage of correct answers was obtained when examining urine samples containing Escherichia coli: Microscopy (78.3%), culture (87.0%) and susceptibility testing (range: 84.3-90.7%).Conclusion: The quality of POC testing in general practice was high when examining urine samples containing the most common uropathogen E. coli. Surprisingly, susceptibility testing was more frequently used than culture. This approach may compromise the treatment decision as only cultures contribute with information about the flora composition and bacterial quantification. Interestingly, microscopy was the least used method even though the result may be reached within a few minutes.Key pointsThe quality of POC tests (microscopy, urine culture, susceptibility testing) performed in general practice was high when examining urine containing E. coli, whereas difficulties were observed for samples including S. saprophyticus or K. pneumoniae.Susceptibility testing was more often performed than urine culture, which indicates a problem as only urine cultures contribute with information about the flora composition and bacterial quantification.
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Affiliation(s)
- Ida Kollerup
- Center for General Practice, Aalborg University, Aalborg, Denmark
| | | | | | | | - Lars Bjerrum
- Section of General Practice and Research Unit for General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
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Izett-Kay M, Barker KL, McNiven A, Toye F. Experiences of urinary tract infection: A systematic review and meta-ethnography. Neurourol Urodyn 2022; 41:724-739. [PMID: 35114012 DOI: 10.1002/nau.24884] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Revised: 12/13/2021] [Accepted: 01/05/2022] [Indexed: 11/10/2022]
Abstract
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.
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Affiliation(s)
- Matthew Izett-Kay
- Department of Urogynaecology, Women's Centre, John Radcliffe Hospital, Oxford University Hospitals FT, Oxford, UK.,Nuffield Department of Women's & Reproductive Health, University of Oxford, Oxford, UK
| | - Karen L Barker
- Physiotherapy Research Unit, Nuffield Orthopaedic Centre, Oxford University Hospitals FT, Oxford, UK
| | - Abigail McNiven
- Nuffield Department of Primary Care Health Sciences, Medical Sociology & Health Experiences Research Group, University of Oxford, Radcliffe Observatory Quarter, Oxford, UK
| | - Francine Toye
- Nuffield Orthopaedic Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.,Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), University of Oxford, Oxford, UK
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Qian Y, Walters SJ, Jacques R, Flight L. Comprehensive review of statistical methods for analysing patient-reported outcomes (PROs) used as primary outcomes in randomised controlled trials (RCTs) published by the UK's Health Technology Assessment (HTA) journal (1997-2020). BMJ Open 2021; 11:e051673. [PMID: 34489292 PMCID: PMC8422492 DOI: 10.1136/bmjopen-2021-051673] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
OBJECTIVES To identify how frequently patient-reported outcomes (PROs) are used as primary and/or secondary outcomes in randomised controlled trials (RCTs) and to summarise what statistical methods are used for the analysis of PROs. DESIGN Comprehensive review. SETTING RCTs funded and published by the United Kingdom's (UK) National Institute for Health Research (NIHR) Health Technology Assessment (HTA) Programme. DATA SOURCES AND ELIGIBILITY HTA reports of RCTs published between January 1997 and December 2020 were reviewed. DATA EXTRACTION Information relating to PRO use and analysis methods was extracted. PRIMARY AND SECONDARY OUTCOME MEASURES The frequency of using PROs as primary and/or secondary outcomes; statistical methods that were used for the analysis of PROs as primary outcomes. RESULTS In this review, 37.6% (114/303) of trials used PROs as primary outcomes, and 82.8% (251/303) of trials used PROs as secondary outcomes from 303 NIHR HTA reports of RCTs. In the 114 RCTs where the PRO was the primary outcome, the most used PRO was the Short-Form 36 (8/114); the most popular methods for multivariable analysis were linear mixed model (45/114), linear regression (29/114) and analysis of covariance (13/114); logistic regression was applied for binary and ordinal outcomes in 14/114 trials; and the repeated measures analysis was used in 39/114 trials. CONCLUSION The majority of trials used PROs as primary and/or secondary outcomes. Conventional methods such as linear regression are widely used, despite the potential violation of their assumptions. In recent years, there is an increasing trend of using complex models (eg, with mixed effects). Statistical methods developed to address these violations when analysing PROs, such as beta-binomial regression, are not routinely used in practice. Future research will focus on evaluating available statistical methods for the analysis of PROs.
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Affiliation(s)
- Yirui Qian
- School of Health and Related Research, The University of Sheffield, Sheffield, UK
| | - Stephen J Walters
- School of Health and Related Research, The University of Sheffield, Sheffield, UK
| | - Richard Jacques
- School of Health and Related Research, The University of Sheffield, Sheffield, UK
| | - Laura Flight
- School of Health and Related Research, The University of Sheffield, Sheffield, UK
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10
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Vellinga A, Farrell K, Fallon R, Hare D, Sutton-Fitzpatrick U, Cormican M. Presentation, Treatment, and Natural Course of Severe Symptoms of Urinary Tract Infections Measured by a Smartphone App: Observational and Feasibility Study. J Med Internet Res 2021; 23:e25364. [PMID: 34477567 PMCID: PMC8449294 DOI: 10.2196/25364] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Revised: 01/04/2021] [Accepted: 03/16/2021] [Indexed: 11/13/2022] Open
Abstract
Background Urinary tract infections (UTIs) are one of the most common conditions in women. Current information on the presentation, management, and natural course of the infection is based on paper diaries filled out and subsequently posted by patients. Objective The aim of this study is to explore the feasibility of a smartphone app to assess the natural course and management of UTIs. Methods A smartphone app was developed to collect data from study participants presenting with symptoms of UTI in general practice. After initial demographic and treatment information, symptom severity was recorded by the patient after a reminder on their smartphone, which occurred twice daily for a period of 7 days or until symptom resolution. Results A total of 181 women aged 18-76 years downloaded the smartphone app. The duration of symptoms was determined from the results of 178 participants. All patients submitted a urine sample, most patients were prescribed an antibiotic (163/181, 90.1%), and 38.7% (70/181) of the patients had a positive culture. Moderately bad or worse symptoms lasted a mean of 3.8 (SD 3.2; median 4) days, and 70.2% (125/178) of the patients indicated that they were cured on day 4 after consultation. This compares with other research assessing symptom duration and management of UTIs using paper diaries. Patients were very positive about the usability of the smartphone app and often found the reminders supportive. On the basis of the feedback and the analysis of the data, some suggestions for improvement were made. Conclusions Smartphone diaries for symptom scores over the course of infections are an efficient and acceptable means of collecting data in research.
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Affiliation(s)
- Akke Vellinga
- School of Medicine, National University of Ireland Galway, Galway, Ireland
| | - Karen Farrell
- School of Medicine, Health Research Board Primary Care Clinical Trials Network Ireland, National University of Ireland Galway, Galway, Ireland
| | - Roisin Fallon
- School of Medicine, Health Research Board Primary Care Clinical Trials Network Ireland, National University of Ireland Galway, Galway, Ireland
| | - Daniel Hare
- Department of Clinical Microbiology, University Hospital Galway, Galway, Ireland
| | | | - Martin Cormican
- Health Service Executive, Antimicrobial Resistance and Infection Control Team, Dublin, Ireland.,Discipline of Bacteriology, National University of Ireland Galway, Galway, Ireland
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11
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Hu YJ, Zhou X, Wang S, Willcox M, Garner C, Brown D, Becque T, Stuart B, Han Z, Chang Q, Moore M, Little P. Diarrhoea Management using Over-the-counter Nutraceuticals in Daily practice (DIAMOND): a feasibility RCT on alternative therapy to reduce antibiotic use. Pilot Feasibility Stud 2021; 7:126. [PMID: 34130752 PMCID: PMC8204461 DOI: 10.1186/s40814-021-00850-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Accepted: 05/03/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Although rarely indicated, antibiotics are commonly used for acute diarrhoea in China. We conducted a randomised, double blind exploratory clinical trial of loperamide, berberine and turmeric for treatment of acute diarrhoea. METHODS Adults with acute uncomplicated diarrhoea aged 18 to 70 were randomised to 4 groups: (A) loperamide; (B) loperamide and berberine; (C) loperamide and turmeric; (D) loperamide, berberine and turmeric. All participants were given rescue ciprofloxacin for use after 48 h if symptoms worsened or were unimproved. Primary endpoints were feasibility and ciprofloxacin use during the 2-week follow-up period. Semi-structured interviews were conducted following recruitment and were analysed thematically. Recruiting doctors, delivery pharmacists and research assistants were blinded to treatment allocation. RESULTS Only 21.5% (278/1295) of patients screened were deemed eligible, and 49% (136/278) of these consented and were entered into the final analysis. Most participants had mild symptoms, because most patients with moderate or severe symptoms wanted to be given antibiotics. Follow-up was good (94% at 2 weeks). Only three participants used rescue antibiotics compared to 67% of acute diarrhoea patients in the hospital during the recruitment period. The median symptom duration was 14 h in group B (interquartile range (IQR) 10-22), 16 h in group D (IQR 10-22), 18 h in group A (IQR 10-33) and 20 h in group C (IQR 16-54). Re-consultation rates were low. There were no serious treatment-related adverse events. Most interviewed participants said that although they had believed antibiotics to be effective for diarrhoea, they were surprised by their quick recovery without antibiotics in this trial. CONCLUSION Although recruitment was challenging because of widespread expectations for antibiotics, patients with mild diarrhoea accepted trying an alternative. The three nutraceuticals therapy require further evaluation in a fully powered, randomised controlled trial among a broader sample. TRIAL REGISTRATION ChiCTR-IPR-17014107.
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Affiliation(s)
- Yanhong Jessika Hu
- Murdoch Children's Research Institute, Royal Children's Hospital, Parkville, Victoria, Australia. .,Department of Paediatrics, The University of Melbourne, Parkville, Victoria, Australia.
| | - Xudong Zhou
- School of Public Health, Zhejiang University, 866 Yuhangtang Road, Zhejiang, 310058, Hangzhou, China
| | - Shanjuan Wang
- Affiliated Hospital of Jiading District Centre, Shanghai Institute of Health Science, No. 1 Chengbei Rd, Jiading Qu, Shanghai Shi, 201800, China
| | - Merlin Willcox
- Primary Care Research Centre, University of Southampton, Aldermoor Health Centre, Aldermoor Close, Southampton, SO16 5ST, United Kingdom
| | - Colin Garner
- Antibiotic Research UK, Genesis 5, York Science Park, Heslington, York, YO10 5DQ, United Kingdom
| | - David Brown
- Alchemy Biomedical Consulting, St Johns Innovation Centre, Cowley Road, Cambridge, CB4 0WS, United Kingdom
| | - Taeko Becque
- Primary Care Research Centre, University of Southampton, Aldermoor Health Centre, Aldermoor Close, Southampton, SO16 5ST, United Kingdom
| | - Beth Stuart
- Primary Care Research Centre, University of Southampton, Aldermoor Health Centre, Aldermoor Close, Southampton, SO16 5ST, United Kingdom
| | - Zongru Han
- Affiliated Hospital of Jiading District Centre, Shanghai Institute of Health Science, No. 1 Chengbei Rd, Jiading Qu, Shanghai Shi, 201800, China
| | - Qin Chang
- Affiliated Hospital of Jiading District Centre, Shanghai Institute of Health Science, No. 1 Chengbei Rd, Jiading Qu, Shanghai Shi, 201800, China
| | - Michael Moore
- Primary Care Research Centre, University of Southampton, Aldermoor Health Centre, Aldermoor Close, Southampton, SO16 5ST, United Kingdom
| | - Paul Little
- Primary Care Research Centre, University of Southampton, Aldermoor Health Centre, Aldermoor Close, Southampton, SO16 5ST, United Kingdom
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12
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Dryden SD, Anastasova S, Satta G, Thompson AJ, Leff DR, Darzi A. Rapid uropathogen identification using surface enhanced Raman spectroscopy active filters. Sci Rep 2021; 11:8802. [PMID: 33888775 PMCID: PMC8062667 DOI: 10.1038/s41598-021-88026-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Accepted: 03/26/2021] [Indexed: 12/01/2022] Open
Abstract
Urinary tract infection is one of the most common bacterial infections leading to increased morbidity, mortality and societal costs. Current diagnostics exacerbate this problem due to an inability to provide timely pathogen identification. Surface enhanced Raman spectroscopy (SERS) has the potential to overcome these issues by providing immediate bacterial classification. To date, achieving accurate classification has required technically complicated processes to capture pathogens, which has precluded the integration of SERS into rapid diagnostics. This work demonstrates that gold-coated membrane filters capture and aggregate bacteria, separating them from urine, while also providing Raman signal enhancement. An optimal gold coating thickness of 50 nm was demonstrated, and the diagnostic performance of the SERS-active filters was assessed using phantom urine infection samples at clinically relevant concentrations (105 CFU/ml). Infected and uninfected (control) samples were identified with an accuracy of 91.1%. Amongst infected samples only, classification of three bacteria (Escherichia coli, Enterococcus faecalis, Klebsiella pneumoniae) was achieved at a rate of 91.6%.
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Affiliation(s)
- Simon D Dryden
- Department of Surgery and Cancer, Imperial College London, St Mary's Hospital, 10Th Floor, QEQM Wing, London, W2 1NY, UK.
| | - Salzitsa Anastasova
- Hamlyn Centre for Robotic Surgery, Imperial College London, London, SW1 2AZ, UK
| | - Giovanni Satta
- Department of Infection, Imperial College NHS Trust, London, W6 8RF, UK
| | - Alex J Thompson
- Department of Surgery and Cancer, Imperial College London, St Mary's Hospital, 10Th Floor, QEQM Wing, London, W2 1NY, UK. .,Hamlyn Centre for Robotic Surgery, Imperial College London, London, SW1 2AZ, UK. .,Department of Surgery and Cancer, Imperial College London, St Mary's Hospital, 2nd Floor, Paterson Building, London, W2 1NY, UK.
| | - Daniel R Leff
- Department of Surgery and Cancer, Imperial College London, St Mary's Hospital, 10Th Floor, QEQM Wing, London, W2 1NY, UK.,Hamlyn Centre for Robotic Surgery, Imperial College London, London, SW1 2AZ, UK
| | - Ara Darzi
- Department of Surgery and Cancer, Imperial College London, St Mary's Hospital, 10Th Floor, QEQM Wing, London, W2 1NY, UK.,Hamlyn Centre for Robotic Surgery, Imperial College London, London, SW1 2AZ, UK
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13
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Seo SH, Jeong IS, Lee EJ. Impact of Obesity on Urinary Tract Infections in Korean Adults: Secondary Data Analysis Using Community-Based Cohort Study. J Korean Acad Nurs 2021; 51:150-161. [PMID: 33993122 DOI: 10.4040/jkan.20228] [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: 09/21/2020] [Revised: 01/19/2021] [Accepted: 02/10/2021] [Indexed: 11/09/2022]
Abstract
PURPOSE This study investigated the incidence of urinary tract infection (UTI) in community-dwelling adults and identified the association between obesity and UTI. METHODS The participants were 4,926 adults aged over 40 years who had no UTIs at the baseline survey of the Korean Genome Epidemiology Study. Obesity was defined according to the cirtieria of Korean Society for the Study of Obesity using body mass index (BMI) data. UTI was defined as those who had self-reported UTI or had either nitrite, or both leukocytes and blood in the urine dipstick test. Hazard ratio (HR) and 95% confidence interval (CI) were calculated using a multivariate Cox proportional hazards regression analysis to identify the association between the obesity and UTI. RESULTS The incidence proportion of UTI was 5.1%, and the incidence density per 1,000 person-years was 25.5. After controlling general characteristics, people with BMI ≥30.0 kg/m² remained 1.66 times (HR = 1.66, 95% CI = 1.06~2.60; p < .05) more likely to have UTI than those with normal weight. This trend was also present in men or people aged ≥ 60 years. Among women aged ≥ 60 years, people with BMI ≥ 30.0 kg/m² were 1.98 times (HR = 1.98, 95% CI = 1.01~3.86; p < .05) more likely to have UTI than those with normal weight. CONCLUSION The BMI ≥ 30.0 kg/m² is a risk factor of UTIs in Korean adult men over 40 years and women aged ≥ 60 years. It is necessary to emphasize the importance of obesity management to men or women aged ≥ 60 years, specifically.
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Affiliation(s)
- Seung Hee Seo
- Department of Urology, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Ihn Sook Jeong
- College of Nursing, Pusan National University, Yangsan, Korea.
| | - Eun Joo Lee
- Department of Nursing, Dong-Eui University, Busan, Korea
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14
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Gbinigie OA, Spencer EA, Heneghan CJ, Lee JJ, Butler CC. Cranberry Extract for Symptoms of Acute, Uncomplicated Urinary Tract Infection: A Systematic Review. Antibiotics (Basel) 2020; 10:12. [PMID: 33375566 PMCID: PMC7824375 DOI: 10.3390/antibiotics10010012] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2020] [Revised: 12/22/2020] [Accepted: 12/23/2020] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND Effective alternatives to antibiotics for alleviating symptoms of acute infections may be appealing to patients and enhance antimicrobial stewardship. Cranberry-based products are already in wide use for symptoms of acute urinary tract infection (UTI). The aim of this review was to identify and critically appraise the supporting evidence. METHODS The protocol was registered on PROSPERO. Searches were conducted of Medline, Embase, Amed, Cinahl, The Cochrane library, Clinicaltrials.gov and WHO International Clinical Trials Registry Platform. We included randomised clinical trials (RCTs) and non-randomised studies evaluating the effect of cranberry extract in the management of acute, uncomplicated UTI on symptoms, antibiotic use, microbiological assessment, biochemical assessment and adverse events. Study risk of bias assessments were made using Cochrane criteria. RESULTS We included three RCTs (n = 688) judged to be at moderate risk of bias. One RCT (n = 309) found that advice to consume cranberry juice had no statistically significant effect on UTI frequency symptoms (mean difference (MD) -0.01 (95% CI: -0.37 to 0.34), p = 0.94)), on UTI symptoms of feeling unwell (MD 0.02 (95% CI: -0.36 to 0.39), p = 0.93)) or on antibiotic use (odds ratio 1.27 (95% CI: 0.47 to 3.43), p = 0.64), when compared with promoting drinking water. One RCT (n = 319) found no symptomatic benefit from combining cranberry juice with immediate antibiotics for an acute UTI, compared with placebo juice combined with immediate antibiotics. In one RCT (n = 60), consumption of cranberry extract capsules was associated with a within-group improvement in urinary symptoms and Escherichia coli load at day 10 compared with baseline (p < 0.01), which was not found in untreated controls (p = 0.72). Two RCTs were under-powered to detect differences between groups for outcomes of interest. There were no serious adverse effects associated with cranberry consumption. CONCLUSION The current evidence base for or against the use of cranberry extract in the management of acute, uncomplicated UTIs is inadequate; rigorous trials are needed.
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Affiliation(s)
- Oghenekome A. Gbinigie
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Primary Care Building, Radcliffe Observatory Quarter, Woodstock Road, Oxford OX2 6GG, UK; (E.A.S.); (C.J.H.); (J.J.L.); (C.C.B.)
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15
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Heinz J, Röver C, Furaijat G, Kaußner Y, Hummers E, Debray T, Hay AD, Heytens S, Vik I, Little P, Moore M, Stuart B, Wagenlehner F, Kronenberg A, Ferry S, Monsen T, Lindbaek M, Friede T, Gagyor I. Strategies to reduce antibiotic use in women with uncomplicated urinary tract infection in primary care: protocol of a systematic review and meta-analysis including individual patient data. BMJ Open 2020; 10:e035883. [PMID: 33004385 PMCID: PMC7534728 DOI: 10.1136/bmjopen-2019-035883] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
INTRODUCTION Uncomplicated urinary tract infection (UTI) in women is a common reason to present in general practice and is usually treated with antibiotics to reduce symptom severity and duration. Results of recent clinical trials indicate that non-antibiotic treatment approaches can also be effective. However, it remains unclear which patients would benefit from antibiotic treatment and which can effectively and safely be treated without antibiotics. This systematic review and meta-analysis aims to estimate the effect of treatment strategies to reduce antibiotic use in comparison with immediate antibiotic treatment and to identify prognostic factors and moderators of treatment effects. A further aim is to identify subgroups of patients benefiting from a specific therapy. METHODS AND ANALYSIS A systematic literature search will be performed to identify randomised controlled trials which investigated the effect of treatment strategies to reduce antibiotic use in female adults with uncomplicated UTI compared with immediate antibiotic treatment. Therefore, the primary outcome of the meta-analysis is incomplete recovery. Anonymised individual patient data (IPD) will be collected. Aggregate data will be used for pairwise comparisons of treatment strategies using meta-analysis models with random effects accounting for potential between-study heterogeneity. Potential effect moderators will be explored in meta-regressions. For IPD, generalised linear mixed models will be used, which may be adjusted for baseline characteristics. Interactions of baseline variables with treatment effects will be explored. These models will be used to assess direct comparisons of treatment, but might be extended to networks. ETHICS AND DISSEMINATION The local institutional review and ethics board judged the project a secondary analysis of existing anonymous data which meet the criteria for waiver of ethics review. Dissemination of the results will be via published scientific papers and presentations. Key messages will be promoted for example, via social media or press releases. PROSPERO REGISTRATION NUMBER CRD42019125804.
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Affiliation(s)
- Judith Heinz
- Department of Medical Statistics, University Medical Center Goettingen, Goettingen, Germany
| | - Christian Röver
- Department of Medical Statistics, University Medical Center Goettingen, Goettingen, Germany
| | - Ghefar Furaijat
- Department of General Practice, University Medical Center Goettingen, Goettingen, Germany
- Department of Emergency Medicine, University Medical Center Goettingen, Goettingen, Germany
| | - Yvonne Kaußner
- Department of General Practice, Julius Maximilians University Wuerzburg Faculty of Medicine, Wuerzburg, Germany
| | - Eva Hummers
- Department of General Practice, University Medical Center Goettingen, Goettingen, Germany
| | - Thomas Debray
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Alastair D Hay
- Centre for Academic Primary Care, University of Bristol, Bristol, UK
| | - Stefan Heytens
- Department of Public Health and Primary Care, University of Ghent, Gent, Belgium
| | - Ingvild Vik
- Department of General Practice, The Antibiotic Centre of Primary Care, Institute of Health and Society, University of Oslo, Oslo, Norway
- Department of Emergency General Practice, Oslo Accident and Emergency Outpatient Clinic, Oslo, Norway
| | - Paul Little
- Primary Care Population Sciences and Medical Education Unit, University of Southampton School of Medicine, Southampton, UK
| | - Michael Moore
- Primary Care Population Sciences and Medical Education Unit, University of Southampton School of Medicine, Southampton, UK
| | - Beth Stuart
- Primary Care Population Sciences and Medical Education Unit, University of Southampton School of Medicine, Southampton, UK
| | - Florian Wagenlehner
- Clinic for Urology, Pediatric Urology and Andrology, Justus Liebig University Giessen Faculty of Medicine, Giessen, Germany
| | - Andreas Kronenberg
- Institute for Infectious Diseases, University of Bern, Bern, Switzerland
| | - Sven Ferry
- Department of Clinical Microbiology, Bacteriology, Umea University, Umea, Sweden
| | - Tor Monsen
- Department of Clinical Microbiology, Bacteriology, Umea University, Umea, Sweden
| | - Morten Lindbaek
- Department of General Practice, The Antibiotic Centre of Primary Care, Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Tim Friede
- Department of Medical Statistics, University Medical Center Goettingen, Goettingen, Germany
| | - Ildiko Gagyor
- Department of General Practice, Julius Maximilians University Wuerzburg Faculty of Medicine, Wuerzburg, Germany
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16
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Diagnosis and Management of UTI in Primary Care Settings-A Qualitative Study to Inform a Diagnostic Quick Reference Tool for Women Under 65 Years. Antibiotics (Basel) 2020; 9:antibiotics9090581. [PMID: 32906671 PMCID: PMC7559568 DOI: 10.3390/antibiotics9090581] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Revised: 08/22/2020] [Accepted: 08/24/2020] [Indexed: 11/17/2022] Open
Abstract
Background: To inform interventions to improve antimicrobial use in urinary tract infections (UTIs) and contribute to a reduction in Escherichia coli bloodstream infection, we explored factors influencing the diagnosis and management of UTIs in primary care. Design: Semi-structured focus groups informed by the Theoretical Domains Framework. Setting: General practice (GP) surgeries in two English clinical commissioning groups (CCGs), June 2017 to March 2018. Participants: A total of 57 GP staff within 8 focus groups. Results: Staff were very aware of common UTI symptoms and nitrofurantoin as first-line treatment, but some were less aware about when to send a urine culture, second-line and non-antibiotic management, and did not probe for signs and symptoms to specifically exclude vaginal causes or pyelonephritis before prescribing. Many consultations were undertaken over the phone, many by nurse practitioners, and followed established protocols that often included urine dipsticks and receptionists. Patient expectations increased use of urine dipsticks, and immediate and 5 days courses of antibiotics. Management decisions were also influenced by patient co-morbidities. No participants had undertaken recent UTI audits. Patient discussions around antibiotic resistance and back-up antibiotics were uncommon compared to consultations for respiratory infections. Conclusions: Knowledge and skill gaps could be addressed with education and clear, accessible, UTI diagnostic and management guidance and protocols that are also appropriate for phone consultations. Public antibiotic campaigns and patient-facing information should cover UTIs, non-pharmaceutical recommendations for "self-care", prevention and rationale for 3 days antibiotic courses. Practices should be encouraged to audit UTI management.
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17
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Is Non-Steroidal Anti-Inflammatory Therapy Non-Inferior to Antibiotic Therapy in Uncomplicated Urinary Tract Infections: a Systematic Review. J Gen Intern Med 2020; 35:1821-1829. [PMID: 32270403 PMCID: PMC7280390 DOI: 10.1007/s11606-020-05745-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Accepted: 02/12/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND Amid growing antimicrobial resistance, there is an increasing focus on antibiotic stewardship efforts to reduce inappropriate antibiotic prescribing. In this context, novel approaches for treating infections without antibiotics are being explored. One such strategy is the use of non-steroidal anti-inflammatory drugs (NSAIDs) for uncomplicated urinary tract infections (UTIs). Therefore, we conducted a systematic review of randomized controlled trials to evaluate the rates of symptom resolution and infectious complications in adult women with uncomplicated UTIs treated with antibiotics versus NSAIDs. METHODS We systematically searched PubMed, CINHAL, Scopus, Web of Science Core Collection, EMBASE, and ClinicalTrials.gov from inception until January 13, 2020, for randomized controlled trials comparing NSAIDs with antibiotics for treatment of uncomplicated UTIs in adult women. Studies comparing symptom resolution between groups were eligible. Two authors screened all studies independently and in duplicate; data were abstracted using a standardized template. Risk of bias was assessed using the Cochrane Collaboration tool. RESULTS Five randomized trials that included 1309 women with uncomplicated UTI met inclusion criteria. Three studies (1130 patients) favored antibiotic therapy in terms of symptom resolution. Two studies (179 patients) found no difference between NSAIDs and antibiotics in terms of symptom resolution. Three studies reported rates of pyelonephritis, two of which found higher rates in patients treated with NSAIDs versus antibiotics. Between two studies that reported this outcome (747 patients), patients randomized to NSAIDs received fewer antibiotic prescriptions compared with those in the antibiotics group. Three studies were at low risk of bias, one had an unclear risk of bias, and one was at high risk of bias. DISCUSSION For the outcomes of symptom resolution and complications in adult women with UTI, evidence favors antibiotics over NSAIDs. PROSPERO CRD42018114133.
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18
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Gadalla AAH, Friberg IM, Kift-Morgan A, Zhang J, Eberl M, Topley N, Weeks I, Cuff S, Wootton M, Gal M, Parekh G, Davis P, Gregory C, Hood K, Hughes K, Butler C, Francis NA. Identification of clinical and urine biomarkers for uncomplicated urinary tract infection using machine learning algorithms. Sci Rep 2019; 9:19694. [PMID: 31873085 PMCID: PMC6928162 DOI: 10.1038/s41598-019-55523-x] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2019] [Accepted: 11/19/2019] [Indexed: 12/14/2022] Open
Abstract
Women with uncomplicated urinary tract infection (UTI) symptoms are commonly treated with empirical antibiotics, resulting in overuse of antibiotics, which promotes antimicrobial resistance. Available diagnostic tools are either not cost-effective or diagnostically sub-optimal. Here, we identified clinical and urinary immunological predictors for UTI diagnosis. We explored 17 clinical and 42 immunological potential predictors for bacterial culture among women with uncomplicated UTI symptoms using random forest or support vector machine coupled with recursive feature elimination. Urine cloudiness was the best performing clinical predictor to rule out (negative likelihood ratio [LR−] = 0.4) and rule in (LR+ = 2.6) UTI. Using a more discriminatory scale to assess cloudiness (turbidity) increased the accuracy of UTI prediction further (LR+ = 4.4). Urinary levels of MMP9, NGAL, CXCL8 and IL-1β together had a higher LR+ (6.1) and similar LR− (0.4), compared to cloudiness. Varying the bacterial count thresholds for urine culture positivity did not alter best clinical predictor selection, but did affect the number of immunological predictors required for reaching an optimal prediction. We conclude that urine cloudiness is particularly helpful in ruling out negative UTI cases. The identified urinary biomarkers could be used to develop a point of care test for UTI but require further validation.
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Affiliation(s)
- Amal A H Gadalla
- Division of Population Medicine, School of Medicine, College of Biomedical and Life Sciences, Cardiff University, Cardiff, United Kingdom.
| | - Ida M Friberg
- Division of Infection & Immunity, School of Medicine, College of Biomedical and Life Sciences, Cardiff University, Cardiff, United Kingdom
| | - Ann Kift-Morgan
- Division of Infection & Immunity, School of Medicine, College of Biomedical and Life Sciences, Cardiff University, Cardiff, United Kingdom
| | - Jingjing Zhang
- Division of Infection & Immunity, School of Medicine, College of Biomedical and Life Sciences, Cardiff University, Cardiff, United Kingdom
| | - Matthias Eberl
- Division of Infection & Immunity, School of Medicine, College of Biomedical and Life Sciences, Cardiff University, Cardiff, United Kingdom.,Systems Immunity Research Institute, Cardiff University, Cardiff, United Kingdom
| | - Nicholas Topley
- Division of Infection & Immunity, School of Medicine, College of Biomedical and Life Sciences, Cardiff University, Cardiff, United Kingdom.,Systems Immunity Research Institute, Cardiff University, Cardiff, United Kingdom
| | - Ian Weeks
- Systems Immunity Research Institute, Cardiff University, Cardiff, United Kingdom.,Clinical Innovation Hub, School of Medicine, College of Biomedical and Life Sciences, Cardiff University, Cardiff, United Kingdom
| | - Simone Cuff
- Division of Infection & Immunity, School of Medicine, College of Biomedical and Life Sciences, Cardiff University, Cardiff, United Kingdom.,Systems Immunity Research Institute, Cardiff University, Cardiff, United Kingdom.,Clinical Innovation Hub, School of Medicine, College of Biomedical and Life Sciences, Cardiff University, Cardiff, United Kingdom
| | - Mandy Wootton
- Specialist Antimicrobial Chemotherapy Unit, Public Health Wales Microbiology Cardiff, University Hospital of Wales, Cardiff, United Kingdom
| | - Micaela Gal
- Division of Population Medicine, School of Medicine, College of Biomedical and Life Sciences, Cardiff University, Cardiff, United Kingdom
| | - Gita Parekh
- Mologic Ltd., Bedford Technology Park, Thurleigh, Bedford, United Kingdom
| | - Paul Davis
- Mologic Ltd., Bedford Technology Park, Thurleigh, Bedford, United Kingdom
| | - Clive Gregory
- Division of Population Medicine, School of Medicine, College of Biomedical and Life Sciences, Cardiff University, Cardiff, United Kingdom
| | - Kerenza Hood
- Centre for Trials Research, School of Medicine, College of Biomedical and Life Sciences, Cardiff University, Cardiff, United Kingdom
| | - Kathryn Hughes
- Division of Population Medicine, School of Medicine, College of Biomedical and Life Sciences, Cardiff University, Cardiff, United Kingdom
| | - Christopher Butler
- Division of Population Medicine, School of Medicine, College of Biomedical and Life Sciences, Cardiff University, Cardiff, United Kingdom.,Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Nick A Francis
- Division of Population Medicine, School of Medicine, College of Biomedical and Life Sciences, Cardiff University, Cardiff, United Kingdom.,Primary Care, Population Sciences and Medical Education, University of Southampton, Southampton, United Kingdom
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19
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Sebesta EM, March A, Sayegh C, Li G, Love M, Badalato GM, Ferdschneider M, Cooper KL. Reducing overprescribing of antibiotics for suspected urinary tract infections in a health sciences campus student health service. Neurourol Urodyn 2019; 39:220-224. [DOI: 10.1002/nau.24173] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Accepted: 09/12/2019] [Indexed: 11/08/2022]
Affiliation(s)
- Elisabeth M. Sebesta
- Department of Urology Columbia University Irving Medical Center New York New York
| | - Anika March
- Student Health Service Columbia University Irving Medical Center New York New York
| | - Christopher Sayegh
- Department of Urology Columbia University Irving Medical Center New York New York
| | - Gen Li
- Department of Biostatistics, Mailman School of Public Health Columbia University New York New York
| | - Michelle Love
- Student Health Service Columbia University Irving Medical Center New York New York
| | - Gina M. Badalato
- Department of Urology Columbia University Irving Medical Center New York New York
| | - Marcy Ferdschneider
- Student Health Service Columbia University Irving Medical Center New York New York
| | - Kimberly L. Cooper
- Department of Urology Columbia University Irving Medical Center New York New York
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Beyer AK, Currea GCC, Holm A. Validity of microscopy for diagnosing urinary tract infection in general practice - a systematic review. Scand J Prim Health Care 2019; 37:373-379. [PMID: 31304845 PMCID: PMC6713105 DOI: 10.1080/02813432.2019.1639935] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
Abstract
Objective: To investigate the validity of microscopy as a diagnostic tool for urinary tract infection in general practice. Methods: (Design/setting) A systematic review was conducted by searching Medline for clinical studies made in general practice, outpatient clinics or similar settings in which the accuracy/validity of microscopy was evaluated with urine culture as the reference standard. Results: Our search resulted in 108 titles. 28 potentially eligible studies were retrieved for full-text reading. We included eight studies involving 4582 patients in this review. The quality of the studies was moderate to high. Specificity ranged from 27% to 100%, sensitivity from 47% to 97%. The variation between studies did not allow for meta-analysis. Conclusion: We did not find substantial evidence to determine the clinical validity of microscopy performed in general practice on urine samples from patients with symptoms of UTI. Key points Urinary tract infection is common in general practice. Methods for precise diagnosis are needed in order to avoid inappropriate treatment. Currently no evidence-based consensus exists regarding the use of urinary microscopy in general practice. We did not find substantial evidence to determine the overall clinical validity of microscopy performed in general practice on urine samples from patients with symptoms of UTI. Light microscopy with oil immersion had high sensitivity and specificity but is time-consuming. Phase-contrast microscopy is quick and had high specificity but lower sensitivity.
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Affiliation(s)
- Anja Kofod Beyer
- Research Unit for General practice and Department of General Practice, University of Copenhagen, København, Denmark
- CONTACT Anja Kofod Beyer Bachelor of medicine, Copenhagen University, Nørregade 10, 1165 København, Denmark
| | | | - Anne Holm
- Research Unit for General practice and Department of General Practice, University of Copenhagen, København, Denmark
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Raftery J, Hanney S, Greenhalgh T, Glover M, Blatch-Jones A. Models and applications for measuring the impact of health research: update of a systematic review for the Health Technology Assessment programme. Health Technol Assess 2018; 20:1-254. [PMID: 27767013 DOI: 10.3310/hta20760] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND This report reviews approaches and tools for measuring the impact of research programmes, building on, and extending, a 2007 review. OBJECTIVES (1) To identify the range of theoretical models and empirical approaches for measuring the impact of health research programmes; (2) to develop a taxonomy of models and approaches; (3) to summarise the evidence on the application and use of these models; and (4) to evaluate the different options for the Health Technology Assessment (HTA) programme. DATA SOURCES We searched databases including Ovid MEDLINE, EMBASE, Cumulative Index to Nursing and Allied Health Literature and The Cochrane Library from January 2005 to August 2014. REVIEW METHODS This narrative systematic literature review comprised an update, extension and analysis/discussion. We systematically searched eight databases, supplemented by personal knowledge, in August 2014 through to March 2015. RESULTS The literature on impact assessment has much expanded. The Payback Framework, with adaptations, remains the most widely used approach. It draws on different philosophical traditions, enhancing an underlying logic model with an interpretative case study element and attention to context. Besides the logic model, other ideal type approaches included constructionist, realist, critical and performative. Most models in practice drew pragmatically on elements of several ideal types. Monetisation of impact, an increasingly popular approach, shows a high return from research but relies heavily on assumptions about the extent to which health gains depend on research. Despite usually requiring systematic reviews before funding trials, the HTA programme does not routinely examine the impact of those trials on subsequent systematic reviews. The York/Patient-Centered Outcomes Research Institute and the Grading of Recommendations Assessment, Development and Evaluation toolkits provide ways of assessing such impact, but need to be evaluated. The literature, as reviewed here, provides very few instances of a randomised trial playing a major role in stopping the use of a new technology. The few trials funded by the HTA programme that may have played such a role were outliers. DISCUSSION The findings of this review support the continued use of the Payback Framework by the HTA programme. Changes in the structure of the NHS, the development of NHS England and changes in the National Institute for Health and Care Excellence's remit pose new challenges for identifying and meeting current and future research needs. Future assessments of the impact of the HTA programme will have to take account of wider changes, especially as the Research Excellence Framework (REF), which assesses the quality of universities' research, seems likely to continue to rely on case studies to measure impact. The HTA programme should consider how the format and selection of case studies might be improved to aid more systematic assessment. The selection of case studies, such as in the REF, but also more generally, tends to be biased towards high-impact rather than low-impact stories. Experience for other industries indicate that much can be learnt from the latter. The adoption of researchfish® (researchfish Ltd, Cambridge, UK) by most major UK research funders has implications for future assessments of impact. Although the routine capture of indexed research publications has merit, the degree to which researchfish will succeed in collecting other, non-indexed outputs and activities remains to be established. LIMITATIONS There were limitations in how far we could address challenges that faced us as we extended the focus beyond that of the 2007 review, and well beyond a narrow focus just on the HTA programme. CONCLUSIONS Research funders can benefit from continuing to monitor and evaluate the impacts of the studies they fund. They should also review the contribution of case studies and expand work on linking trials to meta-analyses and to guidelines. FUNDING The National Institute for Health Research HTA programme.
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Affiliation(s)
- James Raftery
- Primary Care and Population Sciences, Faculty of Medicine, University of Southampton, Southampton General Hospital, Southampton, UK
| | - Steve Hanney
- Health Economics Research Group (HERG), Institute of Environment, Health and Societies, Brunel University London, London, UK
| | - Trish Greenhalgh
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Matthew Glover
- Health Economics Research Group (HERG), Institute of Environment, Health and Societies, Brunel University London, London, UK
| | - Amanda Blatch-Jones
- Wessex Institute, Faculty of Medicine, University of Southampton, Southampton, UK
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Little P, Stuart B, Wingrove Z, Mullee M, Thomas T, Johnson S, Leydon G, Richards-Hall S, Williamson I, Yao L, Zhu S, Moore M. Probiotic capsules and xylitol chewing gum to manage symptoms of pharyngitis: a randomized controlled factorial trial. CMAJ 2017; 189:E1543-E1550. [PMID: 29255098 DOI: 10.1503/cmaj.170599] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/22/2017] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Reducing the use of antibiotics for upper respiratory tract infections is needed to limit the global threat of antibiotic resistance. We estimated the effectiveness of probiotics and xylitol for the management of pharyngitis. METHODS In this parallel-group factorial randomized controlled trial, participants in primary care (aged 3 years or older) with pharyngitis underwent randomization by nurses who provided sequential intervention packs. Pack contents for 3 kinds of material and advice were previously determined by computer-generated random numbers: no chewing gum, xylitol-based chewing gum (15% xylitol; 5 pieces daily) and sorbitol gum (5 pieces daily). Half of each group were also randomly assigned to receive either probiotic capsules (containing 24 × 109 colony-forming units of lactobacilli and bifidobacteria) or placebo. The primary outcome was mean self-reported severity of sore throat and difficulty swallowing (scale 0-6) in the first 3 days. We used multiple imputation to avoid the assumption that data were missing completely at random. RESULTS A total of 1009 individuals consented, 934 completed the baseline assessment, and 689 provided complete data for the primary outcome. Probiotics were not effective in reducing the severity of symptoms: mean severity scores 2.75 with no probiotic and 2.78 with probiotic (adjusted difference -0.001, 95% confidence interval [CI] -0.24 to 0.24). Chewing gum was also ineffective: mean severity scores 2.73 without gum, 2.72 with sorbitol gum (adjusted difference 0.07, 95% CI -0.23 to 0.37) and 2.73 with xylitol gum (adjusted difference 0.01, 95% CI -0.29 to 0.30). None of the secondary outcomes differed significantly between groups, and no harms were reported. INTERPRETATION Neither probiotics nor advice to chew xylitol-based chewing gum was effective for managing pharyngitis. Trial registration: ISRCTN, no. ISRCTN51472596.
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Affiliation(s)
- Paul Little
- Primary Care Group (Little, Stuart, Wingrove, Mullee, Thomas, Johnson, Leydon, Williamson, Moore); Health Economic Analyses Team (Yao, Zhu), Primary Care and Population Sciences Unit, University of Southampton; Patient and Public Involvement Collaborator (Richards-Hall), Southampton, UK
| | - Beth Stuart
- Primary Care Group (Little, Stuart, Wingrove, Mullee, Thomas, Johnson, Leydon, Williamson, Moore); Health Economic Analyses Team (Yao, Zhu), Primary Care and Population Sciences Unit, University of Southampton; Patient and Public Involvement Collaborator (Richards-Hall), Southampton, UK
| | - Zoe Wingrove
- Primary Care Group (Little, Stuart, Wingrove, Mullee, Thomas, Johnson, Leydon, Williamson, Moore); Health Economic Analyses Team (Yao, Zhu), Primary Care and Population Sciences Unit, University of Southampton; Patient and Public Involvement Collaborator (Richards-Hall), Southampton, UK
| | - Mark Mullee
- Primary Care Group (Little, Stuart, Wingrove, Mullee, Thomas, Johnson, Leydon, Williamson, Moore); Health Economic Analyses Team (Yao, Zhu), Primary Care and Population Sciences Unit, University of Southampton; Patient and Public Involvement Collaborator (Richards-Hall), Southampton, UK
| | - Tammy Thomas
- Primary Care Group (Little, Stuart, Wingrove, Mullee, Thomas, Johnson, Leydon, Williamson, Moore); Health Economic Analyses Team (Yao, Zhu), Primary Care and Population Sciences Unit, University of Southampton; Patient and Public Involvement Collaborator (Richards-Hall), Southampton, UK
| | - Sophie Johnson
- Primary Care Group (Little, Stuart, Wingrove, Mullee, Thomas, Johnson, Leydon, Williamson, Moore); Health Economic Analyses Team (Yao, Zhu), Primary Care and Population Sciences Unit, University of Southampton; Patient and Public Involvement Collaborator (Richards-Hall), Southampton, UK
| | - Gerry Leydon
- Primary Care Group (Little, Stuart, Wingrove, Mullee, Thomas, Johnson, Leydon, Williamson, Moore); Health Economic Analyses Team (Yao, Zhu), Primary Care and Population Sciences Unit, University of Southampton; Patient and Public Involvement Collaborator (Richards-Hall), Southampton, UK
| | - Samantha Richards-Hall
- Primary Care Group (Little, Stuart, Wingrove, Mullee, Thomas, Johnson, Leydon, Williamson, Moore); Health Economic Analyses Team (Yao, Zhu), Primary Care and Population Sciences Unit, University of Southampton; Patient and Public Involvement Collaborator (Richards-Hall), Southampton, UK
| | - Ian Williamson
- Primary Care Group (Little, Stuart, Wingrove, Mullee, Thomas, Johnson, Leydon, Williamson, Moore); Health Economic Analyses Team (Yao, Zhu), Primary Care and Population Sciences Unit, University of Southampton; Patient and Public Involvement Collaborator (Richards-Hall), Southampton, UK
| | - Lily Yao
- Primary Care Group (Little, Stuart, Wingrove, Mullee, Thomas, Johnson, Leydon, Williamson, Moore); Health Economic Analyses Team (Yao, Zhu), Primary Care and Population Sciences Unit, University of Southampton; Patient and Public Involvement Collaborator (Richards-Hall), Southampton, UK
| | - Shihua Zhu
- Primary Care Group (Little, Stuart, Wingrove, Mullee, Thomas, Johnson, Leydon, Williamson, Moore); Health Economic Analyses Team (Yao, Zhu), Primary Care and Population Sciences Unit, University of Southampton; Patient and Public Involvement Collaborator (Richards-Hall), Southampton, UK
| | - Michael Moore
- Primary Care Group (Little, Stuart, Wingrove, Mullee, Thomas, Johnson, Leydon, Williamson, Moore); Health Economic Analyses Team (Yao, Zhu), Primary Care and Population Sciences Unit, University of Southampton; Patient and Public Involvement Collaborator (Richards-Hall), Southampton, UK
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Kronenberg A, Bütikofer L, Odutayo A, Mühlemann K, da Costa BR, Battaglia M, Meli DN, Frey P, Limacher A, Reichenbach S, Jüni P. Symptomatic treatment of uncomplicated lower urinary tract infections in the ambulatory setting: randomised, double blind trial. BMJ 2017; 359:j4784. [PMID: 29113968 PMCID: PMC5672899 DOI: 10.1136/bmj.j4784] [Citation(s) in RCA: 83] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Objective To investigate whether symptomatic treatment with non-steroidal anti-inflammatory drugs (NSAIDs) is non-inferior to antibiotics in the treatment of uncomplicated lower urinary tract infection (UTI) in women, thus offering an opportunity to reduce antibiotic use in ambulatory care.Design Randomised, double blind, non-inferiority trial.Setting 17 general practices in Switzerland.Participants 253 women with uncomplicated lower UTI were randomly assigned 1:1 to symptomatic treatment with the NSAID diclofenac (n=133) or antibiotic treatment with norfloxacin (n=120). The randomisation sequence was computer generated, stratified by practice, blocked, and concealed using sealed, sequentially numbered drug containers.Main outcome measures The primary outcome was resolution of symptoms at day 3 (72 hours after randomisation and 12 hours after intake of the last study drug). The prespecified principal secondary outcome was the use of any antibiotic (including norfloxacin and fosfomycin as trial drugs) up to day 30. Analysis was by intention to treat.Results 72/133 (54%) women assigned to diclofenac and 96/120 (80%) assigned to norfloxacin experienced symptom resolution at day 3 (risk difference 27%, 95% confidence interval 15% to 38%, P=0.98 for non-inferiority, P<0.001 for superiority). The median time until resolution of symptoms was four days in the diclofenac group and two days in the norfloxacin group. A total of 82 (62%) women in the diclofenac group and 118 (98%) in the norfloxacin group used antibiotics up to day 30 (risk difference 37%, 28% to 46%, P<0.001 for superiority). Six women in the diclofenac group (5%) but none in the norfloxacin group received a clinical diagnosis of pyelonephritis (P=0.03).Conclusion Diclofenac is inferior to norfloxacin for symptom relief of UTI and is likely to be associated with an increased risk of pyelonephritis, even though it reduces antibiotic use in women with uncomplicated lower UTI.Trial registration ClinicalTrials.gov NCT01039545.
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Affiliation(s)
- Andreas Kronenberg
- Institute for Infectious Diseases, University of Bern, Bern, Switzerland
- Department of Infectious Diseases, Bern University Hospital, University of Bern, Bern, Switzerland
- Medix General Practice Network, Bern, Switzerland
| | - Lukas Bütikofer
- CTU Bern, University of Bern, Bern, Switzerland
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Ayodele Odutayo
- Applied Health Research Centre, Li Ka Shing Knowledge Institute of St Michael's Hospital, Department of Medicine and Institute of Health Policy, Management and Evaluation, University of Toronto, Canada
| | - Kathrin Mühlemann
- Institute for Infectious Diseases, University of Bern, Bern, Switzerland
- Department of Infectious Diseases, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Bruno R da Costa
- Applied Health Research Centre, Li Ka Shing Knowledge Institute of St Michael's Hospital, Department of Medicine and Institute of Health Policy, Management and Evaluation, University of Toronto, Canada
- Institute of Primary Health Care, University of Bern, Bern, Switzerland
| | | | - Damian N Meli
- Medix General Practice Network, Bern, Switzerland
- Institute of Primary Health Care, University of Bern, Bern, Switzerland
| | - Peter Frey
- Institute of Primary Health Care, University of Bern, Bern, Switzerland
| | - Andreas Limacher
- CTU Bern, University of Bern, Bern, Switzerland
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Stephan Reichenbach
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
- Department of Rheumatology, Immunology and Allergology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Peter Jüni
- Applied Health Research Centre, Li Ka Shing Knowledge Institute of St Michael's Hospital, Department of Medicine and Institute of Health Policy, Management and Evaluation, University of Toronto, Canada
- Institute of Primary Health Care, University of Bern, Bern, Switzerland
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Cost-effectiveness of antibiotic treatment of uncomplicated urinary tract infection in women: a comparison of four antibiotics. BJGP Open 2017; 1:bjgpopen17X101097. [PMID: 30564681 PMCID: PMC6169925 DOI: 10.3399/bjgpopen17x101097] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background Urinary tract infections (UTIs) are one of the most common reasons for women to attend primary care. There are four different antibiotics currently recommended in England for treatment of uncomplicated UTI but little evidence on their comparative cost-effectiveness. Aim To assess the relative cost-effectiveness of the four antibiotics currently recommended in England for treatment of uncomplicated UTI in adult women. Design & setting A cost-effectiveness model in adult women with signs and symptoms of uncomplicated UTI in primary care in England treated with fosfomycin, nitrofurantoin, pivmecillinam, or trimethoprim. Method A decision tree economic model of the treatment pathway encompassed up to two rounds of treatment, accounting for different resistance levels. End points included recovery, persistence, pyelonephritis, and/or hospitalisation. Prescription, primary and secondary care treatment, and diagnostic testing costs were aggregated. Cost-effectiveness was assessed as cost per UTI resolved. Results Trimethoprim 200 mg twice daily (for 3 or 7 days) was estimated to be the most cost-effective treatment (£70 per UTI resolved) when resistance was <30%. However, if resistance to trimethoprim was ≥30%, fosfomycin 3 g once became more cost-effective; at resistance levels of ≥35% for trimethoprim, both fosfomycin 3 g once and nitrofurantoin 100 mg twice daily for 7 days were shown to be more cost-effective. Conclusion Knowing local resistance levels is key to effective and cost-effective empirical prescribing. Recent estimates of trimethoprim resistance rates are close to 50%, in which case a single 3 g dose of fosfomycin is likely to be the most cost-effective treatment option.
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Trill J, Simpson C, Webley F, Radford M, Stanton L, Maishman T, Galanopoulou A, Flower A, Eyles C, Willcox M, Hay A, Griffiths G, Little P, Lewith G, Moore M. Uva-ursi extract and ibuprofen as alternative treatments of adult female urinary tract infection (ATAFUTI): study protocol for a randomised controlled trial. Trials 2017; 18:421. [PMID: 28886751 PMCID: PMC5591533 DOI: 10.1186/s13063-017-2145-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2016] [Accepted: 08/14/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Women with acute uncomplicated urine infection are usually treated with antibiotics. One trial has demonstrated that delayed antibiotic treatment offered without symptom relief results in a modest reduction in antibiotic use. There is some evidence that ibuprofen provides symptom relief and reduces antibiotic use. Uva-ursi, a herbal product, has a traditional use for urinary infection symptom relief. We set out to test: in adult women with suspected UTI who accept the delayed prescription strategy: Do NSAIDs or uva-ursi (a herbal product) provide relief from urinary symptoms and reduce antibiotic use. METHODS/DESIGN Adult women with suspected urinary tract infection presenting to primary care will be randomised using a factorial trial design in which patients will be randomised to one of two interventions as below: Group 1 - Uva-ursi + advice to take ibuprofen Group 2 - Placebo + advice to take ibuprofen Group 3 - Uva-ursi + no advice to take ibuprofen Group 4 - Placebo + no advice to take ibuprofen Patients and physicians will be blinded to the randomised group for the herb. The main outcome is symptom severity at days 2-4 recorded in a validated, self-report diary used in previous studies. Secondary outcomes include antibiotic use and symptom duration. In total the trial will require 328 patients in order to achieve at least 90% power for the primary endpoint and 80% for the secondary endpoint. In accordance with CONSORT guidelines all comparative analyses will be conducted on an intention-to-treat basis using SPSS or similar package. DISCUSSION The outcomes from this trial have the potential to modify the current approach to the management of acute urinary symptoms with less dependence on the use of antibiotics. TRIAL REGISTRATION ISRCTN registry, ID: ISRCTN43397016 . Registered on 11 February 2015.
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Affiliation(s)
- Jeanne Trill
- Primary Care and Population Science, University of Southampton Faculty of Medicine, Aldermoor Health Centre, Southampton, SO16 5ST England
| | - Catherine Simpson
- Southampton Clinical Trials Unit, University of Southampton Clinical Trials Unit MP131, Southampton General Hospital, Tremona Road, Southampton, SO16 6YD England
| | - Frances Webley
- Southampton Clinical Trials Unit, University of Southampton Clinical Trials Unit MP131, Southampton General Hospital, Tremona Road, Southampton, SO16 6YD England
| | - Mike Radford
- Southampton Clinical Trials Unit, University of Southampton Clinical Trials Unit MP131, Southampton General Hospital, Tremona Road, Southampton, SO16 6YD England
| | - Louise Stanton
- Southampton Clinical Trials Unit, University of Southampton Clinical Trials Unit MP131, Southampton General Hospital, Tremona Road, Southampton, SO16 6YD England
| | - Tom Maishman
- Southampton Clinical Trials Unit, University of Southampton Clinical Trials Unit MP131, Southampton General Hospital, Tremona Road, Southampton, SO16 6YD England
| | - Angeliki Galanopoulou
- Southampton Clinical Trials Unit, University of Southampton Clinical Trials Unit MP131, Southampton General Hospital, Tremona Road, Southampton, SO16 6YD England
| | - Andrew Flower
- Primary Care and Population Science, University of Southampton Faculty of Medicine, Aldermoor Health Centre, Southampton, SO16 5ST England
| | - Caroline Eyles
- Primary Care and Population Science, University of Southampton Faculty of Medicine, Aldermoor Health Centre, Southampton, SO16 5ST England
| | - Merlin Willcox
- Primary Care and Population Science, University of Southampton Faculty of Medicine, Aldermoor Health Centre, Southampton, SO16 5ST England
| | - Alastair Hay
- Centre for Academic Primary Care, National Institute for Health Research (NIHR) School for Primary Care Research, Population Health Sciences, Bristol Medical School, University of Bristol, Whatley Road, Bristol, BS8 2PS England
| | - Gareth Griffiths
- Southampton Clinical Trials Unit, University of Southampton Clinical Trials Unit MP131, Southampton General Hospital, Tremona Road, Southampton, SO16 6YD England
| | - Paul Little
- Primary Care and Population Science, University of Southampton Faculty of Medicine, Aldermoor Health Centre, Southampton, SO16 5ST England
| | - George Lewith
- Primary Care and Population Science, University of Southampton Faculty of Medicine, Aldermoor Health Centre, Southampton, SO16 5ST England
| | - Michael Moore
- Primary Care and Population Science, University of Southampton Faculty of Medicine, Aldermoor Health Centre, Southampton, SO16 5ST England
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Marques AG, Doi AM, Pasternak J, Damascena MDS, França CN, Martino MDV. Performance of the dipstick screening test as a predictor of negative urine culture. EINSTEIN-SAO PAULO 2017; 15:34-39. [PMID: 28444086 PMCID: PMC5433304 DOI: 10.1590/s1679-45082017ao3936] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2016] [Accepted: 02/13/2017] [Indexed: 11/22/2022] Open
Abstract
Objective To investigate whether the urine dipstick screening test can be used to predict urine culture results. Methods A retrospective study conducted between January and December 2014 based on data from 8,587 patients with a medical order for urine dipstick test, urine sediment analysis and urine culture. Sensitivity, specificity, positive and negative predictive values were determined and ROC curve analysis was performed. Results The percentage of positive cultures was 17.5%. Nitrite had 28% sensitivity and 99% specificity, with positive and negative predictive values of 89% and 87%, respectively. Leukocyte esterase had 79% sensitivity and 84% specificity, with positive and negative predictive values of 51% and 95%, respectively. The combination of positive nitrite or positive leukocyte esterase tests had 85% sensitivity and 84% specificity, with positive and negative predictive values of 53% and 96%, respectively. Positive urinary sediment (more than ten leukocytes per microliter) had 92% sensitivity and 71% specificity, with positive and negative predictive values of 40% and 98%, respectively. The combination of nitrite positive test and positive urinary sediment had 82% sensitivity and 99% specificity, with positive and negative predictive values of 91% and 98%, respectively. The combination of nitrite or leukocyte esterase positive tests and positive urinary sediment had the highest sensitivity (94%) and specificity (84%), with positive and negative predictive values of 58% and 99%, respectively. Based on ROC curve analysis, the best indicator of positive urine culture was the combination of positives leukocyte esterase or nitrite tests and positive urinary sediment, followed by positives leukocyte and nitrite tests, positive urinary sediment alone, positive leukocyte esterase test alone, positive nitrite test alone and finally association of positives nitrite and urinary sediment (AUC: 0.845, 0.844, 0.817, 0.814, 0.635 and 0.626, respectively). Conclusion A negative urine culture can be predicted by negative dipstick test results. Therefore, this test may be a reliable predictor of negative urine culture.
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van Hecke O, Wang K, Lee JJ, Roberts NW, Butler CC. Implications of Antibiotic Resistance for Patients' Recovery From Common Infections in the Community: A Systematic Review and Meta-analysis. Clin Infect Dis 2017; 65:371-382. [PMID: 28369247 PMCID: PMC5850316 DOI: 10.1093/cid/cix233] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2016] [Accepted: 03/14/2017] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Antibiotic use is the main driver for carriage of antibiotic-resistant bacteria. The perception exists that failure of antibiotic treatment due to antibiotic resistance has little clinical impact in the community. METHODS We searched MEDLINE, EMBASE, PubMed, Cochrane Central Register of Controlled Trials, and Web of Science from inception to 15 April 2016 without language restriction. We included studies conducted in community settings that reported patient-level data on laboratory-confirmed infections (respiratory tract, urinary tract, skin or soft tissue), antibiotic resistance, and clinical outcomes. Our primary outcome was clinical response failure. Secondary outcomes were reconsultation, further antibiotic prescriptions, symptom duration, and symptom severity. Where possible, we calculated odds ratios with 95% confidence intervals by performing meta-analysis using random effects models. RESULTS We included 26 studies (5659 participants). Clinical response failure was significantly more likely in participants with antibiotic-resistant Escherichia coli urinary tract infections (odds ratio [OR] = 4.19; 95% confidence interval [CI] = 3.27-5.37; n = 2432 participants), Streptococcus pneumoniae otitis media (OR = 2.51; 95% CI = 1.29-4.88; n = 921 participants), and S. pneumoniae community-acquired pneumonia (OR = 2.15; 95% CI = 1.32-3.51; n = 916 participants). Clinical heterogeneity precluded primary outcome meta-analysis for Staphylococcus aureus skin or soft-tissue infections. CONCLUSIONS Antibiotic resistance significantly impacts on patients' illness burden in the community. Patients with laboratory-confirmed antibiotic-resistant urinary and respiratory-tract infections are more likely to experience delays in clinical recovery after treatment with antibiotics. A better grasp of the risk of antibiotic resistance on outcomes that matter to patients should inform more meaningful discussions between healthcare professionals and patients about antibiotic treatment for common infections.
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Affiliation(s)
- Oliver van Hecke
- Nuffield Department of Primary Care Health Sciences, University of Oxford
| | - Kay Wang
- Nuffield Department of Primary Care Health Sciences, University of Oxford
| | - Joseph J Lee
- Nuffield Department of Primary Care Health Sciences, University of Oxford
| | - Nia W Roberts
- Bodleian Health Care Libraries, Knowledge Centre, Oxford, United Kingdom
| | - Chris C Butler
- Nuffield Department of Primary Care Health Sciences, University of Oxford
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Abstract
Urinary tract infection (UTI) is the most common bacterial infection independent of age. It is also one of the most common causes of hospitalizations for infections among elderly people and the most common indication for antibiotic prescriptions in primary care. Both diagnostics and management of lower and upper urinary tract infections provide challenges in clinical practice due to their high prevalence and recurrence, and worldwide increase of antibiotic resistance. The clinical symptoms of UTI are often uncharacteristic or asymptomatic. The accurate diagnosis and early treatment are crucial due to risk of septicaemia and long-term consequences. Currently the diagnosis of urinary tract infection is based on the presence of clinical symptoms in combination with the results of nitrite strip test indicating the presence of bacteria in urine and semi-quantitative measurement of white blood cells count in urine. Although urine culture is the gold standard in UTI diagnostics it is both time-consuming and costly. Searching for novel biomarkers of UTI has attracted much attention in recent years. The article reviews several promising serum and urine biomarkers of UTI such as leukocyte esterase, C-reactive protein, procalcitonin, interleukins, elastase alpha (1)-proteinase inhibitor, lactofferin, secretory immunoglobulin A, heparin-binding protein, xanthine oxidase, myeloperoxidase, soluble triggering receptor expressed on myeloid cells-1, α-1 microglobulin (α1Mg) and tetrazolium nitroblue test (TNB).
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Zingone F, Iovino P, Santonicola A, Gallotta S, Ciacci C. High risk of lower urinary tract symptoms in patients with irritable bowel syndrome. Tech Coloproctol 2017. [PMID: 28647823 DOI: 10.1007/s10151-017-1653-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND The aim of the present study was to investigate the prevalence of urinary tract infection (UTI) and the risk of lower urinary tract symptoms (LUTS) in women with irritable bowel syndrome (IBS) (including each subtype: constipation, diarrhea, and mixed) compared to women in the general population. METHODS Between January 2014 and December 2015, consecutive adult female patients diagnosed with IBS at the outpatient clinic of the University of Salerno and healthy women with regular bowel habits were enrolled in the study. At baseline, we checked for UTI with a dipstick test and questioned patients about the presence of LUTS in the previous 24 h. RESULTS We enrolled 141 IBS patients and 91 healthy controls in the study. There was no difference in the prevalence of UTI between IBS patients and healthy controls (4.9 vs 3.3%, p = 0.5). When we excluded patients with UTI, we found a 2.79 higher risk of increased urinary frequency [odds ratio (OR) 2.79, 95% confidence interval (CI) 1.37-5.68], a 2.68 higher risk of urinary urgency (OR 2.68, 95% CI 1.04-6.91), and more than three times the risk of having dysuria (OR 3.25, 95% CI 1.06-9.97) in IBS women compared to healthy controls. The risk of having at least one urinary symptom was independent of IBS subtype and IBS severity. CONCLUSIONS Our study shows that IBS women have a similar risk of UTI compared to healthy women even if they complain more of LUTS, independently of IBS subtype and severity.
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Affiliation(s)
- F Zingone
- AOU San Giovanni di Dio e Ruggi di Aragona, Department of Medicine and Surgery, University of Salerno, Salerno, Italy.
- Gastrointestinal Unit, University of Salerno, Via San Leonardo 1, Salerno, Italy.
| | - P Iovino
- AOU San Giovanni di Dio e Ruggi di Aragona, Department of Medicine and Surgery, University of Salerno, Salerno, Italy
| | - A Santonicola
- AOU San Giovanni di Dio e Ruggi di Aragona, Department of Medicine and Surgery, University of Salerno, Salerno, Italy
| | - S Gallotta
- AOU San Giovanni di Dio e Ruggi di Aragona, Department of Medicine and Surgery, University of Salerno, Salerno, Italy
| | - C Ciacci
- AOU San Giovanni di Dio e Ruggi di Aragona, Department of Medicine and Surgery, University of Salerno, Salerno, Italy
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Shinkins B, Yang Y, Abel L, Fanshawe TR. Evidence synthesis to inform model-based cost-effectiveness evaluations of diagnostic tests: a methodological review of health technology assessments. BMC Med Res Methodol 2017; 17:56. [PMID: 28410588 PMCID: PMC5391551 DOI: 10.1186/s12874-017-0331-7] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2016] [Accepted: 03/27/2017] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Evaluations of diagnostic tests are challenging because of the indirect nature of their impact on patient outcomes. Model-based health economic evaluations of tests allow different types of evidence from various sources to be incorporated and enable cost-effectiveness estimates to be made beyond the duration of available study data. To parameterize a health-economic model fully, all the ways a test impacts on patient health must be quantified, including but not limited to diagnostic test accuracy. METHODS We assessed all UK NIHR HTA reports published May 2009-July 2015. Reports were included if they evaluated a diagnostic test, included a model-based health economic evaluation and included a systematic review and meta-analysis of test accuracy. From each eligible report we extracted information on the following topics: 1) what evidence aside from test accuracy was searched for and synthesised, 2) which methods were used to synthesise test accuracy evidence and how did the results inform the economic model, 3) how/whether threshold effects were explored, 4) how the potential dependency between multiple tests in a pathway was accounted for, and 5) for evaluations of tests targeted at the primary care setting, how evidence from differing healthcare settings was incorporated. RESULTS The bivariate or HSROC model was implemented in 20/22 reports that met all inclusion criteria. Test accuracy data for health economic modelling was obtained from meta-analyses completely in four reports, partially in fourteen reports and not at all in four reports. Only 2/7 reports that used a quantitative test gave clear threshold recommendations. All 22 reports explored the effect of uncertainty in accuracy parameters but most of those that used multiple tests did not allow for dependence between test results. 7/22 tests were potentially suitable for primary care but the majority found limited evidence on test accuracy in primary care settings. CONCLUSIONS The uptake of appropriate meta-analysis methods for synthesising evidence on diagnostic test accuracy in UK NIHR HTAs has improved in recent years. Future research should focus on other evidence requirements for cost-effectiveness assessment, threshold effects for quantitative tests and the impact of multiple diagnostic tests.
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Affiliation(s)
- Bethany Shinkins
- Test Evaluation Group, Academic Unit of Health Economics, Leeds Institute of Health Sciences, University of Leeds, Worsely Building, Clarendon Way, Leeds, LS2 9LJ, UK.
| | - Yaling Yang
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG, UK
| | - Lucy Abel
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG, UK
| | - Thomas R Fanshawe
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG, UK
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Fritzenwanker M, Imirzalioglu C, Chakraborty T, Wagenlehner FM. Modern diagnostic methods for urinary tract infections. Expert Rev Anti Infect Ther 2016; 14:1047-1063. [DOI: 10.1080/14787210.2016.1236685] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Dufour AB, Shaffer ML, D'Agata EMC, Habtemariam D, Mitchell SL. Survival After Suspected Urinary Tract Infection in Individuals with Advanced Dementia. J Am Geriatr Soc 2015; 63:2472-2477. [PMID: 26613981 DOI: 10.1111/jgs.13833] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVES To determine whether antimicrobial treatment for suspected urinary tract infections (UTIs) improves survival in nursing home residents with advanced dementia. DESIGN Prospective cohort study. SETTING Thirty-five nursing homes in Boston, Massachusetts. PARTICIPANTS Nursing home residents who experienced at least one suspected UTI over a 12-month period (N = 110); mean participant age 86.4 ± 6.2, 84% female. MEASUREMENTS Analyses were at the level of the UTI episode. Antimicrobial treatment for each suspected UTI was categorized as none, oral, intramuscular, or intravenous or hospitalization. Survival was calculated from the date of suspected UTI episode until death or last known follow-up date. Covariates included resident and episode characteristics. Cox proportional hazards regression was used to examine the association between treatment group and risk of death after adjusting for covariates. RESULTS Residents experienced 196 suspected UTIs over the follow-up period; 33% (n = 36) died during follow-up. There was no antimicrobial use for 25.0% of the 196 suspected UTIs, oral antimicrobial use in 59.7%; intramuscular antimicrobial use in 9.2%, and intravenous antimicrobial use or hospital transfer in 6.1%. After multivariable adjustment, antimicrobial treatment was not significantly associated with mortality (oral, adjusted hazard ratio for death (AHR) = 1.09, 95% confidence interval (CI) = 0.43-2.75; intramuscular, AHR = 0.66, 95% CI = 0.08-5.66; intravenous or hospitalization, AHR = 1.83, 95% CI = 0.44-7.60). CONCLUSION Although the majority of suspected UTIs that nursing home residents with advanced dementia experienced were treated with antimicrobials, treatment was not associated with survival.
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Affiliation(s)
- Alyssa B Dufour
- Hebrew SeniorLife, Institute for Aging Research, Boston, Massachusetts.,Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Michele L Shaffer
- Department of Pediatrics, University of Washington, Seattle, Washington.,Children's Core for Biomedical Statistics, Seattle Children's Research Institute, Seattle, Washington
| | - Erika M C D'Agata
- Division of Infectious Diseases, Rhode Island Hospital, Brown University, Providence, Rhode Island
| | | | - Susan L Mitchell
- Hebrew SeniorLife, Institute for Aging Research, Boston, Massachusetts.,Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
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Ferry SA, E. Holm S, Ferry BM, Monsen TJ. High Diagnostic Accuracy of Nitrite Test Paired with Urine Sediment can Reduce Unnecessary Antibiotic Therapy. Open Microbiol J 2015; 9:150-9. [PMID: 26668667 PMCID: PMC4676423 DOI: 10.2174/1874285801509010150] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2015] [Revised: 05/07/2015] [Accepted: 06/16/2015] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Urinary tract infections (UTIs) are common bacterial infections dominated by lower UTI in women (LUTIW). Symptoms only are insufficient for diagnosis and accordingly, near patient diagnostic tests confidently confirming significant bacteriuria are desirable. The nitrite test (NIT) has low sensitivity, while bacterial and leukocyte counts disjunctively paired in urine sediment microscopy (SED) have high sensitivity. Similar symptomatic cure rates are found post antibiotic vs. placebo therapy in patients with negative cultures. Consequently, prescription on symptoms only implies unnecessary antibiotic therapy. AIMS to evaluate the diagnostic outcomes of NIT, SED and NIT disjunctively paired with SED (NIT+SED) vs. urine culture, with special focus on bladder incubation time (BIT), and to assess if NIT+SED can reduce unnecessary antibiotic therapy. METHODS A diagnostic, primary care, multicentre study including 1070 women with symptoms suggestive of lower UTI. RESULTS Significant bacteriuria was found in 77%. The BIT highly influenced the diagnostic outcomes and the optimal duration was ≥4h with sensitivity of 66, 90 and 95% for NIT, SED and NIT+SED, respectively. SED performed only in NIT negative specimens could reduce unnecessary antibiotics by 10% vs. prescription on symptoms only. The number needed to test with SED to reduce one unnecessary antibiotic course was five patients at BIT ≥4h and six patients at ≤3h or overall. CONCLUSION The BIT highly influences the diagnostic outcomes with the highest accuracy of NIT+SED. Diagnosis of LUTIW with NIT+SED can reduce unnecessary antibiotic therapy and subsequently decrease antimicrobial resistance. TRIAL REGISTRATION The Swedish Medical Product Agency 1995 03 01:151:01783/94.
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Affiliation(s)
- Sven A. Ferry
- Department of Clinical Microbiology, Bacteriology, Umea University, Umea, Sweden
| | - Stig E. Holm
- Department of Medical Microbiology and Immunology, University of Gothenburg, Gothenburg, Sweden
| | | | - Tor J. Monsen
- Department of Clinical Microbiology, Bacteriology, Umea University, Umea, Sweden
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Chalmers L, Cross J, Chu CS, Phyo AP, Trip M, Ling C, Carrara V, Watthanaworawit W, Keereecharoen L, Hanboonkunupakarn B, Nosten F, McGready R. The role of point-of-care tests in antibiotic stewardship for urinary tract infections in a resource-limited setting on the Thailand-Myanmar border. Trop Med Int Health 2015; 20:1281-9. [PMID: 25963224 PMCID: PMC4758398 DOI: 10.1111/tmi.12541] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Objective Published literature from resource‐limited settings is infrequent, although urinary tract infections (UTI) are a common cause of outpatient presentation and antibiotic use. Point‐of‐care test (POCT) interpretation relates to antibiotic use and antibiotic resistance. We aimed to assess the diagnostic accuracy of POCT and their role in UTI antibiotic stewardship. Methods One‐year retrospective analysis in three clinics on the Thailand–Myanmar border of non‐pregnant adults presenting with urinary symptoms. POCT (urine dipstick and microscopy) were compared to culture with significant growth classified as pure growth of a single organism >105 CFU/ml. Results In 247 patients, 82.6% female, the most common symptoms were dysuria (81.2%), suprapubic pain (67.8%) and urinary frequency (53.7%). After excluding contaminated samples, UTI was diagnosed in 52.4% (97/185); 71.1% (69/97) had a significant growth on culture, and >80% of these were Escherichia coli (20.9% produced extended‐spectrum β‐lactamase (ESBL)). Positive urine dipstick (leucocyte esterase ≥1 and/or nitrate positive) compared against positive microscopy (white blood cell >10/HPF, bacteria ≥1/HPF, epithelial cells <5/HPF) had a higher sensitivity (99% vs. 57%) but a lower specificity (47% vs. 89%), respectively. Combined POCT resulted in the best sensitivity (98%) and specificity (81%). Nearly one in ten patients received an antimicrobial to which the organism was not fully sensitive. Conclusion One rapid, cost‐effective POCT was too inaccurate to be used alone by healthcare workers, impeding antibiotic stewardship in a high ESBL setting. Appropriate prescribing is improved with concurrent use and concordant results of urine dipstick and microscopy.
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Affiliation(s)
- Lauren Chalmers
- Shoklo Malaria Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Thailand
| | - Jessica Cross
- Shoklo Malaria Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Thailand
| | - Cindy S Chu
- Shoklo Malaria Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Thailand
| | - Aung Pyae Phyo
- Shoklo Malaria Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Thailand
| | - Margreet Trip
- Shoklo Malaria Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Thailand
| | - Clare Ling
- Shoklo Malaria Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Thailand
| | - Verena Carrara
- Shoklo Malaria Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Thailand
| | - Wanitda Watthanaworawit
- Shoklo Malaria Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Thailand
| | - Lily Keereecharoen
- Shoklo Malaria Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Thailand
| | - Borimas Hanboonkunupakarn
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - François Nosten
- Shoklo Malaria Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Thailand.,Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.,Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
| | - Rose McGready
- Shoklo Malaria Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Thailand.,Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.,Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
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Abstract
Even though diagnosing and treating urinary tract infections (UTIs) in older people can be difficult, it is essential to prevent reduction in the patients' wellbeing. Near-patient testing can be useful, but guidelines on this discuss the use of urine dipstick testing and laboratory culture in some detail. In addition, there are significant differences in the management of males and females, those with recurrent infections, and those with catheters. Community nurses are well placed to assess and manage this common condition, implementing correct treatment and resolution, owing to the close relationships they cultivate with service users. This article discusses the diagnosis and management of UTIs in older people, highlighting the differentials and red flags that need to be addressed urgently.
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Affiliation(s)
- Kirsty Armstrong
- Senior Lecturer and Practitioner in Primary Care; Faculty of Health, Social Care and Education; St George's University of London and Kingston University
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36
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Diagnosing inflammation and infection in the urinary system via proteomics. J Transl Med 2015; 13:111. [PMID: 25889401 PMCID: PMC4396075 DOI: 10.1186/s12967-015-0475-3] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2014] [Accepted: 03/23/2015] [Indexed: 01/11/2023] Open
Abstract
Background Current methodology for the diagnosis of diseases in the urinary system includes patient symptomology, urine analysis and urine culture. Asymptomatic bacteriuria from urethral colonization or indwelling catheters, sample contamination from perineal or vaginal sources, and non-infectious inflammatory conditions can mimic UTIs, leading to uncertainty on medical treatment decisions. Methods Innovative shotgun metaproteomic methods were used to analyze urine sediments from 120 patients also subjected to conventional urinalysis for various clinical reasons including suspected UTIs. The proteomic data were simultaneously searched for the presence of microbial agents, inflammation, immune responses against pathogens, and evidence of urothelial tissue injury. Hierarchical clustering analysis was performed to identify host protein patterns discerning UTI from urethral colonization and vaginal contamination of urine samples. Results Organisms causing more than 98% of all UTIs and commensal microbes of the urogenital and perineal area were identified from 76 urine sediments with detection sensitivities estimated to be similar to urine culture. Proteomic data permitted a thorough evaluation of inflammatory and antimicrobial immune responses. Hierarchical clustering of the data revealed that high abundances of proteins from activated neutrophils were associated with pathogens in most cases, and correlated well with leukocyte esterase activities and leukocyte counts via microscopy. Proteomic data also allowed assessments of urothelial injury, by quantifying proteins highly expressed in red blood cells and contributing to the acute phase response. Lactobacillus and Gardnerella vaginalis were frequently identified suggesting urethral colonization and/or vaginal contamination of urine. Conclusions A metaproteomic approach of interest for routine urine clinical diagnostics is presented. As compared to urinalysis and urine culture methods, the data are derived from a single experiment for a given sample and provide additional insights into presence or absence of inflammatory responses and vaginal contamination of urine specimens. Electronic supplementary material The online version of this article (doi:10.1186/s12967-015-0475-3) contains supplementary material, which is available to authorized users.
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37
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Nitzan O, Elias M, Chazan B, Saliba W. Urinary tract infections in patients with type 2 diabetes mellitus: review of prevalence, diagnosis, and management. Diabetes Metab Syndr Obes 2015; 8:129-36. [PMID: 25759592 PMCID: PMC4346284 DOI: 10.2147/dmso.s51792] [Citation(s) in RCA: 105] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Urinary tract infections are more common, more severe, and carry worse outcomes in patients with type 2 diabetes mellitus. They are also more often caused by resistant pathogens. Various impairments in the immune system, poor metabolic control, and incomplete bladder emptying due to autonomic neuropathy may all contribute to the enhanced risk of urinary tract infections in these patients. The new anti-diabetic sodium glucose cotransporter 2 inhibitors have not been found to significantly increase the risk of symptomatic urinary tract infections. Symptoms of urinary tract infection are similar to patients without diabetes, though some patients with diabetic neuropathy may have altered clinical signs. Treatment depends on several factors, including: presence of symptoms, severity of systemic symptoms, if infection is localized in the bladder or also involves the kidney, presence of urologic abnormalities, accompanying metabolic alterations, and renal function. There is no indication to treat diabetic patients with asymptomatic bacteriuria. Further studies are needed to improve the treatment of patients with type 2 diabetes and urinary tract infections.
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Affiliation(s)
- Orna Nitzan
- Infectious Disease Unit, Ha’emek Medical Center, Afula, Israel
- Bruce Rappaport Faculty of Medicine, Technion–Israel Institute of Technology, Haifa, Israel
- Infectious Disease Unit, Padeh-Poriya Medical Center, Afula, Israel
| | - Mazen Elias
- Bruce Rappaport Faculty of Medicine, Technion–Israel Institute of Technology, Haifa, Israel
- Department of Internal Medicine C, Ha’emek Medical Center, Afula, Israel
| | - Bibiana Chazan
- Infectious Disease Unit, Ha’emek Medical Center, Afula, Israel
- Bruce Rappaport Faculty of Medicine, Technion–Israel Institute of Technology, Haifa, Israel
| | - Walid Saliba
- Bruce Rappaport Faculty of Medicine, Technion–Israel Institute of Technology, Haifa, Israel
- Department of Internal Medicine C, Ha’emek Medical Center, Afula, Israel
- Correspondence: Walid Saliba, Department of Internal Medicine C, Ha’emek Medical Center, Afula 18101, Israel, Tel +972 4 649 5132, Fax +972 4 649 5134, Email
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Little P, Hobbs FDR, Moore M, Mant D, Williamson I, McNulty C, Lasseter G, Cheng MYE, Leydon G, McDermott L, Turner D, Pinedo-Villanueva R, Raftery J, Glasziou P, Mullee M. PRImary care Streptococcal Management (PRISM) study: in vitro study, diagnostic cohorts and a pragmatic adaptive randomised controlled trial with nested qualitative study and cost-effectiveness study. Health Technol Assess 2014; 18:vii-xxv, 1-101. [PMID: 24467988 DOI: 10.3310/hta18060] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Antibiotics are still prescribed to most patients attending primary care with acute sore throat, despite evidence that there is modest benefit overall from antibiotics. Targeting antibiotics using either clinical scoring methods or rapid antigen detection tests (RADTs) could help. However, there is debate about which groups of streptococci are important (particularly Lancefield groups C and G), and uncertainty about the variables that most clearly predict the presence of streptococci. OBJECTIVE This study aimed to compare clinical scores or RADTs with delayed antibiotic prescribing. DESIGN The study comprised a RADT in vitro study; two diagnostic cohorts to develop streptococcal scores (score 1; score 2); and, finally, an open pragmatic randomised controlled trial with nested qualitative and cost-effectiveness studies. SETTING The setting was UK primary care general practices. PARTICIPANTS Participants were patients aged ≥ 3 years with acute sore throat. INTERVENTIONS An internet program randomised patients to targeted antibiotic use according to (1) delayed antibiotics (control group), (2) clinical score or (3) RADT used according to clinical score. MAIN OUTCOME MEASURES The main outcome measures were self-reported antibiotic use and symptom duration and severity on seven-point Likert scales (primary outcome: mean sore throat/difficulty swallowing score in the first 2-4 days). RESULTS The IMI TestPack Plus Strep A (Inverness Medical, Bedford, UK) was sensitive, specific and easy to use. Lancefield group A/C/G streptococci were found in 40% of cohort 2 and 34% of cohort 1. A five-point score predicting the presence of A/C/G streptococci [FeverPAIN: Fever; Purulence; Attend rapidly (≤ 3 days); severe Inflammation; and No cough or coryza] had moderate predictive value (bootstrapped estimates of area under receiver operating characteristic curve: 0.73 cohort 1, 0.71 cohort 2) and identified a substantial number of participants at low risk of streptococcal infection. In total, 38% of cohort 1 and 36% of cohort 2 scored ≤ 1 for FeverPAIN, associated with streptococcal percentages of 13% and 18%, respectively. In an adaptive trial design, the preliminary score (score 1; n = 1129) was replaced by FeverPAIN (n = 631). For score 1, there were no significant differences between groups. For FeverPAIN, symptom severity was documented in 80% of patients, and was lower in the clinical score group than in the delayed prescribing group (-0.33; 95% confidence interval -0.64 to -0.02; p = 0.039; equivalent to one in three rating sore throat a slight rather than moderately bad problem), and a similar reduction was observed for the RADT group (-0.30; -0.61 to 0.00; p = 0.053). Moderately bad or worse symptoms resolved significantly faster (30%) in the clinical score group (hazard ratio 1.30; 1.03 to 1.63) but not the RADT group (1.11; 0.88 to 1.40). In the delayed group, 75/164 (46%) used antibiotics, and 29% fewer used antibiotics in the clinical score group (risk ratio 0.71; 0.50 to 0.95; p = 0.018) and 27% fewer in the RADT group (0.73; 0.52 to 0.98; p = 0.033). No significant differences in complications or reconsultations were found. The clinical score group dominated both other groups for both the cost/quality-adjusted life-years and cost/change in symptom severity analyses, being both less costly and more effective, and cost-effectiveness acceptability curves indicated the clinical score to be the most likely to be cost-effective from an NHS perspective. Patients were positive about RADTs. Health professionals' concerns about test validity, the time the test took and medicalising self-limiting illness lessened after using the tests. For both RADTs and clinical scores, there were tensions with established clinical experience. CONCLUSIONS Targeting antibiotics using a clinical score (FeverPAIN) efficiently improves symptoms and reduces antibiotic use. RADTs used in combination with FeverPAIN provide no clear advantages over FeverPAIN alone, and RADTs are unlikely to be incorporated into practice until health professionals' concerns are met and they have experience of using them. Clinical scores also face barriers related to clinicians' perceptions of their utility in the face of experience. This study has demonstrated the limitation of using one data set to develop a clinical score. FeverPAIN, derived from two data sets, appears to be valid and its use improves outcomes, but diagnostic studies to confirm the validity of FeverPAIN in other data sets and settings are needed. Experienced clinicians need to identify barriers to the use of clinical scoring methods. Implementation studies that address perceived barriers in the use of FeverPAIN are needed. TRIAL REGISTRATION Current Controlled Trials ISRCTN32027234. SOURCE OF FUNDING This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 18, No. 6. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Paul Little
- Primary Care and Population Sciences Unit, University of Southampton, Southampton, UK
| | - F D Richard Hobbs
- Primary Care Clinical Sciences, University of Birmingham, Birmingham, UK
| | - Michael Moore
- Primary Care and Population Sciences Unit, University of Southampton, Southampton, UK
| | - David Mant
- Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Ian Williamson
- Primary Care and Population Sciences Unit, University of Southampton, Southampton, UK
| | - Cliodna McNulty
- Public Health England, Primary Care Unit, Microbiology Laboratory, Gloucestershire Royal Hospital, Gloucester, UK
| | - Gemma Lasseter
- Public Health England, Primary Care Unit, Microbiology Laboratory, Gloucestershire Royal Hospital, Gloucester, UK
| | - M Y Edith Cheng
- Primary Care and Population Sciences Unit, University of Southampton, Southampton, UK
| | - Geraldine Leydon
- Primary Care and Population Sciences Unit, University of Southampton, Southampton, UK
| | - Lisa McDermott
- Primary Care and Population Sciences Unit, University of Southampton, Southampton, UK
| | - David Turner
- Primary Care and Population Sciences Unit, University of Southampton, Southampton, UK
| | | | - James Raftery
- Primary Care and Population Sciences Unit, University of Southampton, Southampton, UK
| | - Paul Glasziou
- Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Mark Mullee
- Primary Care and Population Sciences Unit, University of Southampton, Southampton, UK
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Kjölvmark C, Påhlman LI, Åkesson P, Linder A. Heparin-binding protein: a diagnostic biomarker of urinary tract infection in adults. Open Forum Infect Dis 2014; 1:ofu004. [PMID: 25734078 PMCID: PMC4324176 DOI: 10.1093/ofid/ofu004] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2014] [Accepted: 03/10/2014] [Indexed: 11/25/2022] Open
Abstract
Background. Urinary tract infections (UTIs) are associated with significant morbidity and high frequency of antibiotic prescription. Diagnosing UTI is often difficult, particularly in the critically ill patient and in patients with unspecific and mild symptoms. The standard rapid tests have limited value, and there is a need for more reliable diagnostic tools. Heparin-binding protein (HBP) is released from neutrophils and has previously been studied as a diagnostic and predictive biomarker in different bacterial infections. Methods. This prospective survey enrolled adult patients at 2 primary care units and 2 hospital emergency departments, to investigate in urine HBP as a biomarker of UTI. In addition, urine levels of interleukin-6, white blood cells, and nitrite were analyzed and compared with HBP. Based on symptoms of UTI and microbiological findings, patients were classified into different groups, UTI (cystitis and pyelonephritis) and no UTI. Results. Three hundred ninety patients were evaluated. The prevalence of UTI in the study group was 45.4%. The sensitivity and specificity for HBP in urine as a marker for UTI were 89.2% and 89.8%, respectively. The positive and negative predictive values were 90.2% and 88.8%, respectively. Heparin-binding protein was the best diagnostic marker for UTI, with an area-under-curve value of 0.94 (95% confidence interval, 0.93–0.96). Heparin-binding protein was significantly better in distinguishing cystitis from pyelonephritis, compared with the other markers. Conclusions. An elevated level of HBP in the urine is associated with UTI and may be a useful diagnostic marker in adult patients with a suspected UTI.
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Affiliation(s)
- Charlott Kjölvmark
- Division of Infection Medicine, Hospital of Helsingborg, Helsingborg, Sweden
| | - Lisa I Påhlman
- Department of Clinical Sciences, Division of Infection Medicine, Lund University, Lund, Sweden
| | - Per Åkesson
- Department of Clinical Sciences, Division of Infection Medicine, Lund University, Lund, Sweden
| | - Adam Linder
- Department of Clinical Sciences, Division of Infection Medicine, Lund University, Lund, Sweden ; Centre for Heart Lung Innovation, St. Paul's Hospital, University of British Columbia, Vancouver, Canada
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Antibiotic treatment of urinary tract infection by community pharmacists: a cross-sectional study. Br J Gen Pract 2014; 63:e244-9. [PMID: 23540480 DOI: 10.3399/bjgp13x665206] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND Urinary tract infections (UTIs) are one of the most common conditions seen in female patients within primary care. Community pharmacists are familiar with symptomatic UTI management and supplying trimethoprim under patient group direction (PGD) for moderate-to-severe uncomplicated UTIs could improve patient access to treatment. AIM To compare the care pathway of patients with UTI symptoms attending GP services with those receiving management, including trimethoprim supply under PGD, via community pharmacies. DESIGN AND SETTING Prospective, cross-sectional, mixed methods approach in 10 community pharmacies within NHS Greater Glasgow and Clyde. METHOD Pharmacies invited a purposive sample of female patients to participate. Pharmacists had the option of supplying trimethoprim under PGD to patients with moderate-to-severe infection meeting the PGD inclusion criteria. Data from patient (questionnaires and semi-structured telephone interviews) and pharmacist (questionnaires and semi-structured, face-to-face interviews) were quantitatively and qualitatively analysed. RESULTS Data were recorded on 153 patients, 97 presenting with GP prescriptions and 56 presenting directly in the pharmacy with symptoms suggestive of UTI, of whom 41 received trimethoprim via PGD and 15 received symptomatic management. Both GP adherence to local infection management guidelines and pharmacist application of PGD inclusion/exclusion criteria required improvement. There was demand and support, from patients and pharmacists, for access to antibiotic treatments for UTIs, without prescription, through community pharmacies. CONCLUSION Operating within PGD controls, antibiotic treatments for UTIs could be provided via community pharmacy to improve patient access to treatment which may also maintain antibiotic stewardship and reduce GP workload.
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Stokholm J, Schjørring S, Pedersen L, Bischoff AL, Følsgaard N, Carson CG, Chawes BLK, Bønnelykke K, Mølgaard A, Krogfelt KA, Bisgaard H. Prevalence and predictors of antibiotic administration during pregnancy and birth. PLoS One 2013; 8:e82932. [PMID: 24340068 PMCID: PMC3858309 DOI: 10.1371/journal.pone.0082932] [Citation(s) in RCA: 83] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2013] [Accepted: 10/29/2013] [Indexed: 12/04/2022] Open
Abstract
Background Antibiotic treatment during pregnancy and birth is very common. In this study, we describe the estimated prevalence of antibiotic administration during pregnancy and birth in the COPSAC2010 pregnancy cohort, and analyze dependence on social and lifestyle-related factors. Methods 706 pregnant women from the novel unselected Copenhagen Prospective Study on Asthma in Childhood (COPSAC2010) pregnancy cohort participated in this analysis. Detailed information on oral antibiotic prescriptions during pregnancy filled at the pharmacy was obtained and verified longitudinally. Information on intrapartum antibiotics, social, and lifestyle-factors was obtained by personal interviews. Results The prevalence of antibiotic use was 37% during pregnancy and 33% intrapartum. Lower maternal age at birth; adjusted odds ratio (aOR) 0.94, 95% CI, [0.90-0.98], p = 0.003 and maternal smoking; aOR 1.97, 95% CI, [1.07-3.63], p = 0.030 were associated with use of antibiotics for urinary tract infection during pregnancy. Maternal educational level (low vs. high), aOR 2.32, 95% CI, [1.24-4.35], p = 0.011, maternal asthma; aOR 1.99, 95% CI, [1.33-2.98], p < 0.001 and previous childbirth; aOR 1.80, 95% CI, [1.21-2.66], p = 0.004 were associated with use of antibiotics for respiratory tract infection during pregnancy. Lower gestational age; aOR 0.72, 95% CI, [0.61-0.85], p < 0.001, maternal smoking; aOR 2.84, 95% CI, [1.33-6.06], p = 0.007, and nulliparity; aOR 1.79, 95% CI, [1.06-3.02], p = 0.030 were associated with administration of intrapartum antibiotics in women giving birth vaginally. Conclusion Antibiotic administration during pregnancy and birth may be influenced by social and lifestyle-factors. Understanding such risk factors may guide preventive strategies in order to avoid unnecessary use of antibiotics.
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Affiliation(s)
- Jakob Stokholm
- Copenhagen Prospective Studies on Asthma in Childhood, Health Sciences, University of Copenhagen, Naestved Hospital, Naestved, Denmark
- Copenhagen Prospective Studies on Asthma in Childhood, Health Sciences, University of Copenhagen, Copenhagen University Hospital, Gentofte, Copenhagen, Denmark
| | - Susanne Schjørring
- Department of Microbiological Surveillance and Research, Statens Serum Institut, Copenhagen, Denmark
| | - Louise Pedersen
- Copenhagen Prospective Studies on Asthma in Childhood, Health Sciences, University of Copenhagen, Naestved Hospital, Naestved, Denmark
- Copenhagen Prospective Studies on Asthma in Childhood, Health Sciences, University of Copenhagen, Copenhagen University Hospital, Gentofte, Copenhagen, Denmark
| | - Anne Louise Bischoff
- Copenhagen Prospective Studies on Asthma in Childhood, Health Sciences, University of Copenhagen, Copenhagen University Hospital, Gentofte, Copenhagen, Denmark
| | - Nilofar Følsgaard
- Copenhagen Prospective Studies on Asthma in Childhood, Health Sciences, University of Copenhagen, Copenhagen University Hospital, Gentofte, Copenhagen, Denmark
| | - Charlotte G. Carson
- Copenhagen Prospective Studies on Asthma in Childhood, Health Sciences, University of Copenhagen, Copenhagen University Hospital, Gentofte, Copenhagen, Denmark
| | - Bo L. K. Chawes
- Copenhagen Prospective Studies on Asthma in Childhood, Health Sciences, University of Copenhagen, Copenhagen University Hospital, Gentofte, Copenhagen, Denmark
| | - Klaus Bønnelykke
- Copenhagen Prospective Studies on Asthma in Childhood, Health Sciences, University of Copenhagen, Copenhagen University Hospital, Gentofte, Copenhagen, Denmark
| | - Anne Mølgaard
- Copenhagen Prospective Studies on Asthma in Childhood, Health Sciences, University of Copenhagen, Copenhagen University Hospital, Gentofte, Copenhagen, Denmark
| | - Karen A. Krogfelt
- Department of Microbiological Surveillance and Research, Statens Serum Institut, Copenhagen, Denmark
| | - Hans Bisgaard
- Copenhagen Prospective Studies on Asthma in Childhood, Health Sciences, University of Copenhagen, Copenhagen University Hospital, Gentofte, Copenhagen, Denmark
- * E-mail:
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Leydon GM, McDermott L, Moore M, Williamson I, Hobbs FDR, Lambton T, Cooper R, Henderson H, Little P. A qualitative study of GP, NP and patient views about the use of rapid streptococcal antigen detection tests (RADTs) in primary care: 'swamped with sore throats?'. BMJ Open 2013; 3:e002460. [PMID: 23558734 PMCID: PMC3641470 DOI: 10.1136/bmjopen-2012-002460] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2012] [Accepted: 02/05/2013] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE To explore patient and healthcare professionals' (HCP) views of clinical scores and rapid streptococcal antigen detection tests (RADTs) for acute sore throat. DESIGN Qualitative semistructured interview study. SETTING UK primary care. PARTICIPANTS General practitioners (GPs), nurse practitioners (NPs) and patients from general practices across Hampshire, Oxfordshire and the West Midlands who were participating in the Primary Care Streptococcal Management (PRISM) study. METHOD Semistructured, face-to-face and phone interviews were conducted with GPs, NPs and patients from general practices across Hampshire, Oxfordshire and the West Midlands. RESULTS 51 participants took part in the study. Of these, 42 were HCPs (29 GPs and 13 NPs) and 9 were patients. HCPs could see a positive role for RADTs in terms of reassurance, as an educational tool for patients, and for aiding inexperienced practitioners, but also had major concerns about RADT use in clinical practice. Particular concerns included the validity of the tests (the role of other bacteria, and carrier states), the tension and possible disconnect with clinical assessment and intuition, the issues of time and resource use and the potential for medicalisation of self-limiting illness. In contrast, however, experience of using RADTs over time seemed to make some participants more positive about using the tests. Moreover, patients were much more positive about the place of RADTs in providing reassurance and in limiting their antibiotic use. CONCLUSIONS It is unlikely that RADTs will have a (comfortable) place in clinical practice in the near future until health professionals' concerns are met, and they have direct experience of using them. The routine use of clinical scoring systems for acute upper respiratory illness also face important barriers related to clinicians' perceptions of their utility in the face of clinician experience and intuition.
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Affiliation(s)
- Gerry M Leydon
- Department of Primary Care and Population Sciences, University of Southampton, Southampton, UK
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D'Agata E, Loeb MB, Mitchell SL. Challenges in assessing nursing home residents with advanced dementia for suspected urinary tract infections. J Am Geriatr Soc 2013; 61:62-6. [PMID: 23311553 DOI: 10.1111/jgs.12070] [Citation(s) in RCA: 121] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVES To describe the presentation of suspected urinary tract infections (UTIs) in nursing home (NH) residents with advanced dementia and how they align with minimum criteria to justify antimicrobial initiation. DESIGN Twelve-month prospective study. SETTING Twenty-five NHs. PARTICIPANTS Two hundred sixty-six NH residents with advanced dementia. MEASUREMENTS Charts were abstracted monthly for documentation of suspected UTI episodes to determine whether episodes met minimum criteria to initiate antimicrobial therapy according to consensus guidelines. RESULTS Seventy-two residents experienced 131 suspected UTI episodes. Presenting symptoms and signs for these episodes are mental status change (44.3%), fever (20.6%), hematuria (6.9%), dysuria (3.8%), costovertebral tenderness (2.3%), urinary frequency (1.5%), rigor (1.5%), urgency (0%), and suprapubic pain (0%). Only 21 (16.0%) episodes met minimal criteria to initiate antimicrobial therapy based on signs and symptoms. Of the 110 episodes that lacked minimum criteria to justify antimicrobial initiation, 82 (74.5%) were treated with antimicrobial therapy. Urinalyses and urine culture results were available for 101 episodes, of which 80 (79.2%) had positive results on both tests. The proportion of episodes with a positive urinalysis and culture was similar for those that met (83.3%) and did not meet (78.3%) minimum criteria (P = .06). CONCLUSION The symptoms and signs necessary to meet minimum criteria to support antimicrobial initiation for UTIs are frequently absent in NH residents with advanced dementia. Antimicrobial therapy is prescribed for the majority of suspected UTIs that do not meet these minimum criteria. Urine specimens are frequently positive regardless of symptoms. These observations underscore the need to reconsider the diagnosis and the initiation of treatment for suspected UTIs in advanced dementia.
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Affiliation(s)
- Erika D'Agata
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts 02215, USA.
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Zegers BSHJ, Uiterwaal CCSPM, Verpoorten CC, Christiaens MMH, Kimpen JJLL, de Jong-de Vos van Steenwijk CCCE, van Gool JJD. Home screening for bacteriuria in children with spina bifida and clean intermittent catheterization. BMC Infect Dis 2012; 12:264. [PMID: 23082909 PMCID: PMC3507913 DOI: 10.1186/1471-2334-12-264] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2012] [Accepted: 10/17/2012] [Indexed: 11/20/2022] Open
Abstract
Background Significant bacteriuria (SBU) and urinary tract infections (UTIs) are common in patients with spina bifida and neuropathic detrusor sphincter dysfunction. Laboratory agar plated culture is the gold standard to establish SBU. It has the disadvantage of diagnostic and subsequent therapeutic delay. Leukocyte esterase tests (LETs) and dip slides proved to be useful in the general populations to exclude SBU and UTI. The aim of this study was to evaluate the reliability of LET and dip slide in children with spina bifida without symptoms of UTI. The reliability in children with asymptomatic SBU was not studied before. Methods In one hundred and twelve children with spina bifida on clean intermittent catheterization LETs and dip slides were compared with laboratory cultures. Both tests and agar plated cultures were performed on catheterized urine samples. The hypothesis was that the home tests are as accurate as laboratory cultures. Results A SBU was found in 45 (40%) of the 112 laboratory cultures. A negative LET excluded SBU (negative predictive value 96%), while a positive LET had a positive predictive value of 72%. The false positive rate was 28%. Dip slide determination of bacterial growth had no added value, other than serving as transport medium. Conclusions In spina bifida children, leukocyte esterase testing can be used to exclude significant bacteriuria at home, while dip slide tests have no added value to diagnose or exclude significant bacteriuria.
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Affiliation(s)
- Bas S H J Zegers
- Department of Pediatrics, Máxima Medical Center Veldhoven, The Netherlands.
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Tsikas D, Suchy MT, Mitschke A, Beckmann B, Gutzki FM. Measurement of nitrite in urine by gas chromatography-mass spectrometry. Methods Mol Biol 2012; 844:277-293. [PMID: 22262450 DOI: 10.1007/978-1-61779-527-5_20] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
Nitric oxide (NO) is enzymatically produced from L-arginine and has a variety of biological functions. Autoxidation of NO in aqueous media yields nitrite (O = N-O(-)). NO and nitrite are oxidized in erythrocytes by oxyhemoglobin to nitrate (NO(3)(-)). Nitrate reductases from bacteria reduce nitrate to nitrite. Nitrite and nitrate are ubiquitous in nature, they are present throughout the body and they are excreted in the urine. Nitrite in urine has been used for several decades as an indicator and measure of bacteriuria. Since the identification of nitrite as a metabolite of NO, circulating nitrite is also used as an indicator of NO synthesis and is considered an NO storage form. In contrast to plasma nitrite, the significance of nitrite in the urine beyond bacteriuria is poorly investigated and understood. This chapter describes a gas chromatography-mass spectrometry (GC-MS) protocol for the quantitative determination of nitrite in urine of humans. Although the method is useful for detection and quantification of bacteriuria, the procedures described herein are optimum for urinary nitrite in conditions other than urinary tract infection. The method uses [(15)N]nitrite as internal standard and pentafluorobenzyl bromide as the derivatization agent. Derivatization is -performed on 100-μL aliquots and quantification of toluene extracts by selected-ion monitoring of m/z 46 for urinary nitrite and m/z 47 for the internal standard in the electron-capture negative-ion chemical ionization mode.
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Affiliation(s)
- Dimitrios Tsikas
- Institute of Clinical Pharmacology, Hannover Medical School, Hannover 30623, Germany
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Del Mar C. Urinary tract infections in healthy women: a revolution in management? BMC FAMILY PRACTICE 2010; 11:42. [PMID: 20504297 PMCID: PMC2885322 DOI: 10.1186/1471-2296-11-42] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/15/2010] [Accepted: 05/26/2010] [Indexed: 11/10/2022]
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Giesen LGM, Cousins G, Dimitrov BD, van de Laar FA, Fahey T. Predicting acute uncomplicated urinary tract infection in women: a systematic review of the diagnostic accuracy of symptoms and signs. BMC FAMILY PRACTICE 2010; 11:78. [PMID: 20969801 PMCID: PMC2987910 DOI: 10.1186/1471-2296-11-78] [Citation(s) in RCA: 82] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/15/2010] [Accepted: 10/24/2010] [Indexed: 11/10/2022]
Abstract
Background Acute urinary tract infections (UTI) are one of the most common bacterial infections among women presenting to primary care. However, there is a lack of consensus regarding the optimal reference standard threshold for diagnosing UTI. The objective of this systematic review is to determine the diagnostic accuracy of symptoms and signs in women presenting with suspected UTI, across three different reference standards (102 or 103 or 105 CFU/ml). We also examine the diagnostic value of individual symptoms and signs combined with dipstick test results in terms of clinical decision making. Methods Searches were performed through PubMed (1966 to April 2010), EMBASE (1973 to April 2010), Cochrane library (1973 to April 2010), Google scholar and reference checking. Studies that assessed the diagnostic accuracy of symptoms and signs of an uncomplicated UTI using a urine culture from a clean-catch or catherised urine specimen as the reference standard, with a reference standard of at least ≥ 102 CFU/ml were included. Synthesised data from a high quality systematic review were used regarding dipstick results. Studies were combined using a bivariate random effects model. Results Sixteen studies incorporating 3,711 patients are included. The weighted prior probability of UTI varies across diagnostic threshold, 65.1% at ≥ 102 CFU/ml; 55.4% at ≥ 103 CFU/ml and 44.8% at ≥ 102 CFU/ml ≥ 105 CFU/ml. Six symptoms are identified as useful diagnostic symptoms when a threshold of ≥ 102 CFU/ml is the reference standard. Presence of dysuria (+LR 1.30 95% CI 1.20-1.41), frequency (+LR 1.10 95% CI 1.04-1.16), hematuria (+LR 1.72 95%CI 1.30-2.27), nocturia (+LR 1.30 95% CI 1.08-1.56) and urgency (+LR 1.22 95% CI 1.11-1.34) all increase the probability of UTI. The presence of vaginal discharge (+LR 0.65 95% CI 0.51-0.83) decreases the probability of UTI. Presence of hematuria has the highest diagnostic utility, raising the post-test probability of UTI to 75.8% at ≥ 102 CFU/ml and 67.4% at ≥ 103 CFU/ml. Probability of UTI increases to 93.3% and 90.1% at ≥ 102 CFU/ml and ≥ 103 CFU/ml respectively when presence of hematuria is combined with a positive dipstick result for nitrites. Subgroup analysis shows improved diagnostic accuracy using lower reference standards ≥ 102 CFU/ml and ≥ 103 CFU/ml. Conclusions Individual symptoms and signs have a modest ability to raise the pretest-risk of UTI. Diagnostic accuracy improves considerably when combined with dipstick tests particularly tests for nitrites.
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Affiliation(s)
- Leonie G M Giesen
- HRB Centre for Primary Care Research, Department of General Practice, Royal College of Surgeons in Ireland, Beaux Lane House, Lower Mercer Street, Dublin 2, Ireland.
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Schmiemann G, Kniehl E, Gebhardt K, Matejczyk MM, Hummers-Pradier E. The diagnosis of urinary tract infection: a systematic review. DEUTSCHES ARZTEBLATT INTERNATIONAL 2010; 107:361-7. [PMID: 20539810 DOI: 10.3238/arztebl.2010.0361] [Citation(s) in RCA: 164] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/06/2009] [Accepted: 08/26/2009] [Indexed: 11/27/2022]
Abstract
BACKGROUND Urinary tract infections (UTI) are among the leading reasons for treatment in adult primary care medicine, accounting for a considerable percentage of antibiotic prescriptions. Because this problem is so common and so significant in routine clinical practice, a high level of diagnostic accuracy is essential. Antibiotics should not be prescribed excessively, particularly in view of the increasing prevalence of antibiotic resistance. METHOD Systematic review of relevant articles that were retrieved by a search of the Medline, Embase, and Cochrane Library databases. The recommendations of selected international guidelines were also taken into account, as were the German national quality standards for microbiological diagnosis. RESULTS The diagnosis of UTI by clinical criteria alone has an error rate of approximately 33%. The use of refined diagnostic algorithms does not completely eliminate uncertainty. CONCLUSION With the aid of a small number of additional diagnostic criteria, antibiotic treatment for UTI can be provided more specifically and thus more effectively. Differentiating UTI from asymptomatic bacteriuria, which usually requires no treatment, can lower the frequency of unnecessary antibiotic prescriptions.
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Affiliation(s)
- Guido Schmiemann
- Institut für Allgemeinmedizin, Medizinische Hochschule Hannover, Hannover, Germany.
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