The Paradigm Shift to Non-Treatment of Asymptomatic Bacteriuria

Management of Asymptomatic Bacteriuria in Non-Catheterized Adults

Understanding the management of asymptomatic bacteriuria (ASB) is important given the prevalence of the condition, associated risks in certain patient populations, and the risks associated with inappropriate antibiotic administration. Generally, screening and treatment is only recommended in pregnant women and in those undergoing urologic procedures that will violate the urothelium. Knowing the appropriate time to screen and treat ASB is critical for managing high-risk patients and preventing the growth of antibiotic resistance. Recent research into the protective nature of avirulent strains of Escherichia coli might offer a new approach to management of ASB.

Genotypic and phenotypic characterisation of asymptomatic bacteriuria (ABU) isolates displaying bacterial interference against multi-drug resistant uropathogenic E. Coli

Escherichia coli can colonise the urogenital tract of individuals without causing symptoms of infection, in a condition referred to as asymptomatic bacteriuria (ABU). ABU isolates can protect the host against symptomatic urinary tract infections (UTIs) by bacterial interference against uropathogenic E. coli (UPEC). The aim of this study was to investigate the genotypic and phenotypic characteristics of five ABU isolates from midstream urine samples of adults. Comparative genomic and phenotypic analysis was conducted including an antibiotic resistance profile, pangenome analysis, and a putative virulence profile. Based on the genome analysis, the isolates consisted of one from phylogroup A, three from phylogroup B2, and one from phylogroup D. Two of the isolates, PUTS 58 and SK-106-1, were noted for their lack of antibiotic resistance and virulence genes compared to the prototypic ABU strain E. coli 83,972. This study provides insights into the genotypic and phenotypic profiles of uncharacterised ABU isolates, and how relevant fitness and virulence traits can impact their potential suitability for therapeutic bacterial interference.

The Diagnosis and Treatment of Adult Urinary Tract Infections in the Emergency Department

Emergency medicine has been called the art of "making complicated clinical decisions with limited information." This description is particularly relevant in the case of diagnosis and treatment of urinary tract infections (UTIs). Although common, UTIs are often challenging to diagnose given the presence of non-specific signs and symptoms and over-reliance on laboratory findings. This review provides an interdisciplinary interpretation of the primary literature and practice guidelines, with a focus on diagnostic and antimicrobial stewardship in the emergency department.

Online Search Strategies and Results From a Crowdsourced Survey on Asymptomatic Bacteriuria

IMPORTANCE

Despite the prevalence of asymptomatic bacteriuria (ASB), what proportion of the population is aware of this condition and the quality of internet resources are currently unknown.

OBJECTIVE

This study aimed to use an online crowdsourcing platform to explore general knowledge and internet search strategies, along with the quality of information, on ASB.

STUDY DESIGN

An online survey was administered through a crowdsourcing platform to women 50 years or older via Qualtrics, which is a sophisticated online survey tool. Participants completed a survey on ASB, and participants were asked how they would search the internet for information both on urinary test results and on ASB. Outcomes included survey responses, and qualitative data were coded and analyzed thematically. χ2 Testing and regression modeling were used to look for variables associated with concern for ASB.

RESULTS

There were a total of 518 participants who passed attention check qualifications, and only 45 respondents (8.7%) had heard of ASB. Many were concerned about progress to a worsening infection (n = 387 [77.6%]). When controlling for confounders, education beyond a college degree was not associated with a lower concern for ASB when compared with those with a high school education or less (adjusted odds ratio, 0.63; 95% confidence interval, 0.25-1.55; P = 0.31). Medical providers were the target audience for a majority of the websites, and many of the patient-facing results were of poor quality.

CONCLUSIONS

Our national survey of women demonstrated a prevalent knowledge deficit surrounding ASB. We must seek to create high-quality, readily available, patient-facing information to increase awareness of ASB, allay concerns, and increase antibiotic stewardship.

Decision-making and Treatment Preferences Surrounding Bacteriuria in Nonpregnant Women: A Qualitative Investigation

INTRODUCTION AND HYPOTHESIS

Best practices suggest nontreatment for asymptomatic bacteriuria in a nonpregnant population, yet there is little literature on patient preference or understanding of asymptomatic bacteriuria treatment. We hypothesize that there might be core factors that affect antibiotic preferences and care-seeking decisions for urinary tract infection and asymptomatic bacteriuria in a postmenopausal population.

METHODS

We performed semi-structured interviews with postmenopausal individuals who had been previously treated for at least one patient-reported urinary tract infection. Interviews covered a discussion about their approach to seeking antibiotics for management and knowledge/preferences for asymptomatic bacteriuria management. Two authors independently coded the interviews and identified a set of symptom-related knowledge and experiences that relate to care-seeking and treatment preferences. We then graphically represented a mental model of antibiotic-seeking practices as an influence diagram, illustrating how knowledge and values affect preferences for care.

RESULTS

We performed 30 interviews of participants with a mean age of 69.4 (SD 6.4). Among participants, there were four core factors that influence antibiotic seeking for bacteriuria. Participants noted concern for sequelae from untreated bacteria as their primary motivation, but also noted past experiences, information sources, and testing results as themes that affected their mental model surrounding bacteriuria treatment.

CONCLUSIONS

The cognitive approach to care-seeking and treatment preference for bacteriuria is influenced by a few central factors. An improved ability to allay concerns either by provider discussions or educational materials are necessary to bridge the gap from the existence of evidence-based guidelines to patient and provider comfort with adherence to these guidelines.

Implementing diagnostic stewardship to improve diagnosis of urinary tract infections across three medical centers: A qualitative assessment

BACKGROUND

Urine-culture diagnostic stewardship aims to decrease misdiagnosis of urinary tract infections (UTIs); however, these interventions are not widely adopted. We examined UTI diagnosis and management practices to identify barriers to and facilitators of diagnostic stewardship implementation.

METHODS

Using a qualitative descriptive design, we conducted semistructured interviews at 3 Veterans' Affairs medical centers. Interviews were conducted between November 2021 and May 2022 via Zoom videoconferencing using an interview guide and visual prototypes of proposed interventions. Interviewees were asked about current practices and thoughts on proposed interventions for urine-culture ordering, processing, and reporting. We used a rapid analysis matrix approach to summarize key interview findings and compare practices and perceptions across sites.

RESULTS

We interviewed 31 stakeholders and end users. All sites had an antimicrobial stewardship program but limited initiatives targeting appropriate diagnosis and management of UTIs. The majority of those interviewed identified the importance of diagnostic stewardship. Perceptions of specific interventions ranged widely by site. For urine-culture ordering, all 3 sites agreed that documentation of symptomology would improve culturing practices but did not want it to interrupt workflow. Representatives at 2 sites expressed interest in conditional urine-culture processing and 1 was opposed. All sites had similar mechanisms to report culture results but varied in perceptions of the proposed interventions. Feedback from end users was used to develop a general diagnostic stewardship implementation checklist.

CONCLUSION

Interviewees thought diagnostic stewardship was important. Qualitative assessment involving key stakeholders in the UTI diagnostic process improved understanding of site-specific beliefs and practices to better implement interventions for urine-culture ordering, processing, and reporting.

Urinary Tract Infections: The Current Scenario and Future Prospects

Urinary tract infections (UTIs) are among the most common bacterial infections worldwide, occurring in both community and healthcare settings. Although the clinical symptoms of UTIs are heterogeneous and range from uncomplicated (uUTIs) to complicated (cUTIs), most UTIs are usually treated empirically. Bacteria are the main causative agents of these infections, although more rarely, other microorganisms, such as fungi and some viruses, have been reported to be responsible for UTIs. Uropathogenic Escherichia coli (UPEC) is the most common causative agent for both uUTIs and cUTIs, followed by other pathogenic microorganisms, such as Klebsiella pneumoniae, Proteus mirabilis, Enterococcus faecalis, and Staphylococcus spp. In addition, the incidence of UTIs caused by multidrug resistance (MDR) is increasing, resulting in a significant increase in the spread of antibiotic resistance and the economic burden of these infections. Here, we discuss the various factors associated with UTIs, including the mechanisms of pathogenicity related to the bacteria that cause UTIs and the emergence of increasing resistance in UTI pathogens.

Diagnosis and Antibiotic Treatment of Urinary Tract Infections in Danish General Practice: A Quality Assessment

Rational antibiotic treatment of urinary tract infections (UTI) is important. To improve the quality of antibiotic treatment of UTI, it is essential to obtain insight into diagnostic approaches and prescribing patterns in general practice. The aim of this study was to investigate the quality of diagnostics and treatment of UTI in general practice by means of quality indicators (QIs). QIs provide a quantitative measure of quality and are defined by a numerator (the number of patients receiving a specific investigation or treatment) and a denominator (the number of patients included in the quality assessment). For adult patients with suspected UTI, practices registered the following: age, sex, risk factors, symptoms and signs, examinations, diagnosis and treatment. The levels of the QIs were compared with their corresponding standards. Half of the patients diagnosed with lower UTI or pyelonephritis fulfilled the diagnostic criteria for UTI: characteristic UTI symptoms and clear signs of bacteriuria, respectively. Urinalysis was performed for nearly all patients, including patients without characteristic symptoms of UTI. One-fourth of the patients with suspected lower UTI were treated with antibiotics despite no urinalysis and nearly half received antibiotics despite an inconclusive dipstick test. Pivmecillam was the preferred antibiotic. The findings of this study indicate that there is room for improvement in the management of UTI in Danish general practice.

The data and the reality: urine cultures and emergency medicine physicians

BACKGROUND AND OBJECTIVES

The IDSA has published guidelines for the treatment of urinary tract infections, recommending limiting treatment to symptomatic patients and pregnant females. Our objective is to elucidate current practice patterns among emergency physicians (EPs) in treating positive urine cultures in various clinical situations.

METHODS

This study employed a cross-sectional design utilizing a questionnaire addressing nine common scenarios encountered by EPs in the follow-up of a positive urine culture. The questionnaire was conducted using RedCap and distributed via email to current and former physicians and residents across our hospital network. Demographic information included years of training and practice setting. For each of nine clinical scenarios, Physicians were asked if they would treat with antibiotics. Results were then analyzed by tabulating percentage of responses and 95% confidence intervals.

RESULTS

Of 120 respondents, 40.8% worked in academic centers with emergency medicine residencies, 37.5% in large community hospitals, and 20.67% in small community hospitals. Responses came from 14 residents, 33 attendings < 5 years out of training, 23 attendings 5-9 years out of training, 37 attendings 10-20 years out of training, and 13 attendings > 20 beyond training. Asymptomatic young women were treated by 34.2% (95% CI 25.91-43.46%) while asymptomatic elderly women were treated by 50% (95% CI 40.79-59.21%) of EPs. All EPs (95% CI 96.13-100%) chose to treat a symptomatic male and 99.2% (95% CI 94.77-99.96%) chose to treat an asymptomatic pregnant female. Elderly females after a fall were treated by 63.3% (95% CI 54-71.8%) of EPs while elderly males with confusion and a fall were treated by 96.7% (95% CI 91.18-98.93%). Asymptomatic males with a chronic Foley catheter were treated by 28.2% (95% CI 20.67-37.4%) of EPs and 46.7% (95%CI 37.59-55.97%) would treat an asymptomatic middle-aged female with diabetes. Finally, 92.5% (95% CI 85.85-96.3%) of EPs chose to treat an asymptomatic kidney transplant patient.

CONCLUSION

EPs in varied training stages and practice settings have significant practice variation in the treatment of positive urine cultures, particularly in the geriatric population, often prescribing antibiotics to patients where clear, specific and data-driven IDSA guidelines suggest treatment is unnecessary and potentially harmful.

Antimicrobial Stewardship for the Infusion Nurse

The consequences of antimicrobial overuse are complex. Censoring overuse requires strategic efforts directed at tailoring antimicrobial prescribing habits. Antimicrobial stewardship combats the negative consequences for patients and society. All members of the health care team can influence stewardship efforts in the patient treated for infectious diseases. Many of the potent antimicrobials used today are given by infusion, providing an exceptional opportunity for the infusion nurse to become a crucial part of the antimicrobial stewardship team. The goal of this article is to explain why antimicrobials are worth caring for and preserving, as well as to define the role of the infusion nurse in the antimicrobial stewardship team.

Antibiotic prescribing among elderly living in long-term care facilities versus elderly living at home: a Danish registry-based study

BACKGROUND

The objective of this study was to compare antibiotic prescription rates in Denmark among elderly living in long-term care facilities to elderly living at home, with regards to total antibiotic use and antibiotic use for urinary tract infection.

METHODS

This is an observational registry-based study. The study population included all elderly Danish residents aged ≥75 years in 2016. Linear regression models were used to examine the difference in antibiotic prescription rates between elderly living in long-term care facilities and elderly living at home. Results were adjusted for age, sex and comorbidity, the latter assessed via the Charlson Comorbidity Index.

RESULTS

The study population consisted of 416,627 elderly. Regression models showed that elderly living in long-term care facilities were prescribed 1.7 [CI 1.7-1.7] prescriptions/individual/year more than elderly living at home. For urinary tract infections the difference between elderly living in long-term care facilities and elderly living at home was 1.2 [CI 1.2-1.3] prescriptions/individual/year.

CONCLUSIONS

Elderly living in long-term care facilities have a higher antibiotic prescribing rate than elderly living at home, despite controlling for age, sex and comorbidity. This indicates that long-term care facilities continuously should be a focus for antibiotic stewardship interventions.

Incidence of urosepsis or pyelonephritis after uncomplicated urinary tract infection in older women

INTRODUCTION AND HYPOTHESIS

Our primary aim was to describe the incidence of the diagnosis of urosepsis or pyelonephritis during the 60 days following initial evaluation of an uncomplicated urinary tract infection (UTI) among female Medicare beneficiaries ≥ 65 years of age.

STUDY DESIGN

This was a retrospective cohort study of women ≥ 65 years of age undergoing evaluation for an incident, uncomplicated urinary tract infection (UTI) between the years 2011-2018 included in the Medicare 5% Limited Data Set (LDS). We grouped women into age categories of 65-74 years, 75-84 years, or > 84 years old. We excluded women with possible complicated UTI, those hospitalized within 60 days prior to index UTI evaluation, and those residing in a nursing home and place of service consistent with an inpatient setting/facility. The association between age and risk of each outcome was estimated with Cox proportional hazards models, controlling for relevant comorbidities.

RESULTS

Between 2011-2018, 169,958 women met our inclusion/exclusion criteria and were evaluated for uncomplicated UTI. In total, 2935 (1.7%) had a subsequent diagnosis of either urosepsis (n = 2848, 1.6%) or pyelonephritis (n = 145, 0.08%). In adjusted analysis, the hazard of urosepsis was significantly higher for women > 84 years (aHR 1.49, 95% CI 1.38, 1.65; p < 0.01) and those aged 75-84 (aHR 1.24, 95% CI 1.13, 1.37; p < 0.01) compared to those aged 65-74 years. In contrast, age group was not significantly associated with the hazard for pyelonephritis.

CONCLUSIONS

Urosepsis and pyelonephritis are very uncommon after evaluation of incident uncomplicated UTI in female medical beneficiaries ≥ 65 years of age.

Screening Biomarkers and Constructing a Predictive Model for Symptomatic Urinary Tract Infection and Asymptomatic Bacteriuria in Patients Undergoing Cutaneous Ureterostomy: A Metagenomic Next-Generation Sequencing Study

Objectives. To investigate the clinical diagnostic value of differential flora as biomarkers in patients with symptomatic urinary tract infection (UTI) and asymptomatic bacteriuria (ASB) undergoing cutaneous ureterostomy based on metagenomic next-generation sequencing and construct predictive models to provide a scientific reference for clinical diagnosis and treatment. Material and Methods. According to standard procedures, samples were taken from each patient for routine tests (urine, ureteral stent, and skin swab around the stoma). Cytokine levels in the blood were also detected. Urinary microflora were measured by mNGS, and potential biomarkers for distinguishing UTI and ASB were identified by differential flora. Finally, we generated the predictive models for ASB and UTI using the Lasso method and cytokine levels. Results. Urine culture was performed for 50 patients with cutaneous ureterostomy; 44 of these patients developed bacteriuria. The incidence of symptomatic bacteriuria was 54.55%. Biomarker analysis showed that Propionimicrobium lymphophilum, Staphylococcus haemolyticus, Stenotrophomonas maltophilia, Ralstonia insidiosa, and Aspergillus sydowii all had good predictive performance and were combined in a single model. The predictive model exhibited good prediction performance (area under the curve $\left(\text{AUC}\right)=0.8729$ , $\text{sensitivity}=80\%$ , $\text{specificity}=83.3\%$ , and $\text{cutoff}=1.855$ ). We also identified a significant negative correlation between the weight sum of the abundance for these five characteristic pathogens (Sum_weighted_Reads) and levels of the cytokine IL-6 and IL-1β ( $P<0.05$ ). Conclusion. mNGS had a higher positive detection rate for pathogens in urine samples. The selected differential bacteria can be used as biomarkers of ASB and UTI, and the prediction model has good predictive performance. Analysis also showed that the occurrence of symptoms was related to individual immunity. Combined with the Sum_weighted_Reads cutoff and cytokine levels (IL-6 and IL-1β) of differential flora, it was possible to judge the severity of symptoms in cutaneous ureterostomy patients with bacteriuria and provide new insights for the treatment and intervention of ASB and UTI.

Postoperative Pseudomonas aeruginosa endophthalmitis associated with asymptomatic bacteriuria

An 86-year-old man with diabetes and a history of prostate cancer, indwelling urinary catheter and Pseudomonas aeruginosa bacteriuria presented on day 4 post left phacoemulsification cataract extraction and intraocular lens implant with signs and symptoms of postoperative endophthalmitis. Vitreous sample was positive for P. aeruginosa Prompt treatment with intravitreal antibiotics was initiated followed by anterior chamber washout with pars plana vitrectomy; however, the visual outcome was poor.

Effect of asymptomatic bacteriuria on readmissions and rate of urosepsis after ureterorenoscopy for urolithiasis

Objective:

This study aims to assess whether the rate of readmissions after ureterorenoscopy (URS) is dependent on results of urine microscopy, culture and sensitivity (MC&S) or nitrite dipstick test performed before the procedure.

Patients and Methods:

All patients attending for ureteroscopy for stone disease over 12 months were included and had urine dipstick performed immediately prior to the surgery with mid-stream urine (MSU) sample sent for culture. Asymptomatic bacteriuria (ABU) was not treated before ureteroscopy. All included patients received standard antibiotic prophylaxis. Readmissions within 30 days of the procedure were evaluated.

Results:

A total 120 ureteroscopies were included, of which 20% had ABU. Eight patients (6.67%) were readmitted due to all procedure-related complications; among them, five (4.17%) were readmitted with urinary tract infection (UTI). Readmission rates with UTIs were similar for patients with sterile urine and those who had untreated ABU. Of those patients who were readmitted with UTI, all had a negative nitrite result on preoperative urine dipstick specimens. Most patients (54.17%) who had ABU also had a negative urinary nitrite test.

Conclusions:

Screening and routine treatment of ABU before ureteroscopy for urolithiasis may be unnecessary provided patients have standard antibiotic prophylaxis. Moreover, urine nitrite testing before ureteroscopy may not be a useful screening test for ABU before ureteroscopy.

Level of evidence:

2

Nursing home residents with suspected urinary tract infections: a diagnostic accuracy study

Background

Urinary tract infections (UTIs) are one of the most common infections in nursing homes (NHs). A high error rate of a UTI diagnosis based solely on clinical criteria is to be expected in older persons as they often present infections in an atypical way. A study was set up to assess the diagnostic value of signs/symptoms and urine dipstick testing in identifying UTIs in NH residents and to explore whether C-reactive protein (CRP) measured by point-of-care testing (POCT) can help in the diagnosis.

Methods

During a three month prospective multicentre study, urine sampling for culture, POCT CRP and urinary dipstick testing were performed in each NH resident with a suspected UTI. UTIs were defined according to Stone et al., i.e. criteria based upon the presence of a set of signs/symptoms and a positive urine culture.

Results

Eleven NHs and 1 263 residents participated. Sixteen out of 137 recorded UTI suspicions were confirmed. Acute dysuria (positive likelihood ratio (LR +): 7.56, 95% confidence interval (CI): 3.94–14.5) and acute suprapubic pain (LR + : 11.4, 95% CI: 3.58–35.9) were found to be significant predictors. The combined nitrite and leucocyte esterase urine dipstick test (one or both positive) had a 96.0% negative predictive value (95% CI: 80.5–99.3%). The sensitivity of a positive CRP test (≥ 5 mg/L) was 60.0% (95% CI: 32.3–83.7%). Antimicrobials were prescribed in 60.2% of suspected but unconfirmed UTIs and in 92.3% of confirmed UTIs.

Conclusions

Using a stringent definition, only 11.7% of our suspicions were confirmed. Besides acute dysuria and suprapubic pain, we were not able to prove that any other clinical sign/symptom or POCT CPR adds useful information to the UTI diagnosis. We confirmed the findings of earlier research that urine dipstick tests are useful in ruling out UTIs and identified a potential overuse of antimicrobials in our NH population.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-022-02866-2.

Substantial overlap between symptomatic and asymptomatic genitourinary microbiota states

BACKGROUND

The lack of a definition of urinary microbiome health convolutes diagnosis of urinary tract infections (UTIs), especially when non-traditional uropathogens or paucity of bacteria are recovered from symptomatic patients in routine standard-of-care urine tests. Here, we used shotgun metagenomic sequencing to characterize the microbial composition of asymptomatic volunteers in a set of 30 longitudinally collected urine specimens. Using permutation tests, we established a range of asymptomatic microbiota states, and use these to contextualize the microbiota of 122 urine specimens collected from patients with suspected UTIs diagnostically categorized by standard-of-care urinalysis within that range. Finally, we used a standard-of-care culture protocol to evaluate the efficiency of culture-based recovery of the urinary microbiota.

RESULTS

The majority of genitourinary microbiota in individals suspected to have UTI overlapped with the spectrum of asymptomatic microbiota states. Longitudinal characterization of the genitourinary microbiome in urine specimens collected from asymptomatic volunteers revealed fluctuations of microbial functions and taxonomy over time. White blood cell counts from urinalysis suggested that urine specimens categorized as 'insignificant', 'contaminated', or 'no-growth' by conventional culture methods frequently showed signs of urinary tract inflammation, but this inflammation is not associated with genitourinary microbiota dysbiosis. Comparison of directly sequenced urine specimens with standard-of-care culturing confirmed that culture-based diagnosis biases genitourinary microbiota recovery towards the traditional uropathogens Escherichia coli and Klebsiella pneumoniae.

CONCLUSION

Here, we utilize shotgun metagenomic sequencing to establish a baseline of asymptomatic genitourinary microbiota states. Using this baseline we establish substantial overlap between symptomatic and asymptomatic genitourinary microbiota states. Our results establish that bacterial presence alone does not explain the onset of clinical symptoms. Video Abstract.

A review of the current concepts in canine urinary tract infections

Traditionally, urinary tract infections (UTIs) have been categorised as either uncomplicated or complicated in veterinary medicine, with treatment differing for the two categories. In human medicine, there is an additional category: Asymptomatic bacteriuria, which is the presence of bacteriuria without symptoms of infection. Escherichia coli (E.coli) is the most common bacterial species involved in UTIs in dogs. Clinical signs can be absent in dogs with complicated UTIs, and this has been likened to asymptomatic bacteriuria (ASB) in people and has been termed subclinical bacteriuria (SBU) with the treatment recommendations for SBU in dogs have been adapted from human recommendations. There is a shift in the current treatment of UTIs to help minimise the development of antimicrobial resistance. Routine screening of dogs with conditions that may predispose them to UTIs has been discouraged as has the treatment of SBU. This has been due to the increase in antimicrobial resistance (AMR).

Antimicrobial utilization and stewardship in patients with uncomplicated urinary tract infections managed by pharmacists in the community: A sub-study of the RxOUTMAP trial

BACKGROUND

Urinary tract infections (UTIs) often lead to suboptimal antibacterial use. Pharmacists are accessible primary care professionals who have an important role to play in antimicrobial stewardship. Our objective was to evaluate the appropriateness of pharmacists' antibacterial prescribing for patients with uncomplicated UTI.

METHODS

We conducted a prospective registry trial with 39 community pharmacies in New Brunswick, Canada. Adult patients were enrolled if they presented to the pharmacy with either symptoms of UTI with no current antibacterial treatment (pharmacist-initial arm) or an antibacterial prescription for UTI from a physician (physician-initial arm). Pharmacists assessed patients; patients with complicating factors or red flags for systemic illness or pyelonephritis were excluded. Pharmacists prescribed antibacterial therapy or modified antibacterial therapy, provided education only, or referred to a physician, as appropriate. Antibacterial therapy prescribed was compared between study arms.

RESULTS

Seven hundred fifty patients were enrolled (87% pharmacist-initial arm). The most commonly prescribed agents in the pharmacist-initial arm were nitrofurantoin (88.4%), sulfamethoxazole-trimethoprim (TMP-SMX) (7.8%), and fosfomycin (2.1%); in the physician-initial arm, nitrofurantoin (55.3%), TMP-SMX (25.5%), and fluoroquinolones (10.6%) were prescribed. Therapy was guideline concordant for 95.1% of patients in the pharmacist-initial arm and 35.1% of patients in the physician-initial arm (p < 0.001). For guideline-discordant therapy from physicians, pharmacists prescribed to optimize therapy for 45.9% of patients.

CONCLUSION

Treatment was highly guideline concordant when pharmacist initiated, with physicians prescribing longer treatment durations and more fluoroquinolones. This represents an important opportunity for antimicrobial stewardship interventions by pharmacists in the community.

Evaluation of asymptomatic bacteruria management before and after antimicrobial stewardship program implementation: retrospective study

Background

The Infectious Diseases Society of America (IDSA) recommends against screening for and/or treating asymptomatic bacteriuria (ASB). This study aims to evaluate the inappropriate use of antibiotics in ASB before and after Antimicrobial Stewardship Program (ASP) implementation and advance towards its appropriate use.

Method

We performed a retrospective study of patients diagnosed with ASB from 2016 to 2019 at a tertiary hospital in Saudi Arabia. This study included hospitalized patients ≥ 18 years old who had a positive urine culture with no documented signs or symptoms of urinary tract infection We excluded pregnant women, solid organ transplant patients, patient on active chemotherapy, and patients about to undergo urological surgery.

Results

A total of 716 patients with a positive urine culture were screened. Among these, we identified 109 patients with ASB who were included in our study. The rate of inappropriate antibiotic use was 95% during the study period. The implementation of the ASP Program was associated with a significant reduction in the use of carbapenems (P = 0.04) and an increase in the use of cephalosporins (P = 0.01). However, overprescribing antimicrobial agents was a concern in both eras. Approximately 90% of the microorganisms identified were gram-negative bacteria. Of those, 38.7% were multidrug-resistant strains.

Conclusion

The urine culture order in ASB is considered relatively small number; however, it showed a high rate of the inappropriate use of antibiotics when there is an order of urine culture in both era. ASP ought to focus on targeting the ordering physician, promoting awareness and/or organizational interventions that appear to reduce the incidence of overtreatment.

Complicated urinary tract infection in patients with benign prostatic hyperplasia

Complicated urinary tract infection (UTI) is a symptomatic urinary infection accompanied by functional or structural abnormalities of the genitourinary tract. Benign prostatic hyperplasia (BPH) is a major cause of lower urinary tract obstruction in male patients, and bladder outlet obstruction (BOO) secondary to BPH can lead to UTIs in men. However, no evidence has clearly shown that UTI in the aging male population is associated with either post-void residual urine or BOO. Screening for the presence of bacteriuria is recommended prior to any procedure manipulating the urinary tract, and imaging studies of the upper urinary tract are recommended to identify underlying abnormalities. Recurrent or persistent UTI in men with BPH is an indication for surgical treatment. Asymptomatic bacteriuria should be screened for and treated before transurethral resection of the prostate (TURP). In addition, antibiotic prophylaxis reduced the risk of UTI in patients undergoing TURP. The choice of specific antimicrobial for prophylaxis should be based on local pathogen prevalence and individual antibiotic susceptibility. Patients with severe systemic infections require hospitalization, and empirical therapy should include an intravenous antimicrobial regimen. Further prospective studies are needed to refine the treatment process for complicated UTI in patients diagnosed with BPH.

Asymptomatic Bacteriuria and Pyuria in Premenopausal Women

BACKGROUND

Asymptomatic bacteriuria and pyuria in healthy women often trigger inappropriate antimicrobial treatment, but there is a paucity of data on their prevalence and persistence.

METHODS

To evaluate the prevalence and persistence of asymptomatic bacteriuria and pyuria in women at high risk of recurrent urinary tract infection, we conducted an observational cohort study in 104 healthy premenopausal women with a history of recurrent urinary tract infection with daily assessments of bacteriuria, pyuria, and urinary symptoms over a 3-month period.

RESULTS

The mean age of participants was 22 years, and 74% were white. Asymptomatic bacteriuria events (urine cultures with colony count ≥105 CFU/mL of a uropathogen on days with no symptomatic urinary tract infection diagnosed) occurred in 45 (45%) women on 159 (2.5%) of 6283 days. Asymptomatic bacteriuria events were most commonly caused by Escherichia coli, which was present on 1.4% of days, with a median duration of 1 day (range, 1-10). Pyuria occurred in 70 (78%) of 90 evaluable participants on at least 1 day and 25% of all days on which no symptomatic urinary tract infection was diagnosed. The positive predictive value of pyuria for E. coli asymptomatic bacteriuria was 4%.

CONCLUSIONS

In this population of healthy women at high risk of recurrent urinary tract infection, asymptomatic bacteriuria is uncommon and, when present, rarely lasts more than 2 days. Pyuria, on the other hand, is common but infrequently associated with bacteriuria or symptoms. These data strongly support recommendations not to screen for or treat asymptomatic bacteriuria or pyuria in healthy, nonpregnant women.

Outpatient Urinary Tract Infections in an Era of Virtual Healthcare: Trends From 2008 to 2017

BACKGROUND

Urinary tract infections (UTIs) occur commonly, but recent data on UTI rates are scarce. It is unknown how the growth of virtual healthcare delivery affects outpatient UTI management and trends in the United States.

METHODS

From 1 January 2008 to 31 December 2017, UTIs from outpatient settings (office, emergency, and virtual visits) were identified from electronic health records at Kaiser Permanente Southern California using multiple UTI definitions. Annual rates estimated by Poisson regression were stratified by sex, care setting, age, and race/ethnicity. Annual trends were estimated by linear or piecewise Poisson regression.

RESULTS

UTIs occurred in 1 065 955 individuals. Rates per 1000 person-years were 53.7 (95% confidence interval [CI], 50.6-57.0) by diagnosis code with antibiotic and 25.8 (95% CI, 24.7-26.9) by positive culture. Compared to office and emergency visits, UTIs were increasingly diagnosed in virtual visits, where rates by diagnosis code with antibiotic increased annually by 21.2% (95% CI, 16.5%-26.2%) in females and 29.3% (95% CI, 23.7%-35.3%) in males. Only 32% of virtual care diagnoses had a culture order. Overall, UTI rates were highest and increased the most in older adults. Rates were also higher in Hispanic and white females and black and white males.

CONCLUSIONS

Outpatient UTI rates increased from 2008 to 2017, especially in virtual care and among older adults. Virtual care is important for expanding access to health services, but strategies are needed in all outpatient care settings to ensure accurate UTI diagnosis and reduce inappropriate antibiotic treatment.

Active bacterial modification of the host environment through RNA polymerase II inhibition

Unlike pathogens, which attack the host, commensal bacteria create a state of friendly coexistence. Here, we identified a mechanism of bacterial adaptation to the host niche, where they reside. Asymptomatic carrier strains were shown to inhibit RNA polymerase II (Pol II) in host cells by targeting Ser2 phosphorylation, a step required for productive mRNA elongation. Assisted by a rare, spontaneous loss-of-function mutant from a human carrier, the bacterial NlpD protein was identified as a Pol II inhibitor. After internalization by host cells, NlpD was shown to target constituents of the Pol II phosphorylation complex (RPB1 and PAF1C), attenuating host gene expression. Therapeutic efficacy of a recombinant NlpD protein was demonstrated in a urinary tract infection model, by reduced tissue pathology, accelerated bacterial clearance, and attenuated Pol II-dependent gene expression. The findings suggest an intriguing, evolutionarily conserved mechanism for bacterial modulation of host gene expression, with a remarkable therapeutic potential.

The impact of health care provider relationships and communication dynamics on urinary tract infection management and antibiotic utilization for long-term care facility residents treated in the emergency department: A qualitative study

BACKGROUND

For older adults, over diagnosis of urinary tract infections (UTI) is a primary driver of inappropriate antibiotic use. This risk is increased for patients in long-term care facilities (LTCF), especially as they transition back and forth to emergency departments (ED). In this study, we aimed to understand how health care provider communication and relationship dynamics affect LTCF residents treated in the ED to identify barriers to antibiotic stewardship for UTIs.

METHODS

We conducted semi-structured interviews with nurses and physicians from LTCFs and EDs, guided by the Systems Engineering Initiative for Patient Safety framework. Data were systematically coded and underwent iterative, conventional, content analysis.

RESULTS

We interviewed 16 LTCF and 16 ED providers across Wisconsin. ED and LTCF nurses have a critical role in both intrafacility and interfacility communication. Fragmented communication and interprofessional power dynamics were identified barriers to optimal antibiotic prescribing for UTIs. Identified strategies to overcome these issues included using objective diagnostic criteria, development of communication scripts, and nurse-to-nurse education.

CONCLUSIONS

Our qualitative approach revealed important insights about how communication and relationship dynamics influence UTI diagnosis and optimal antibiotic stewardship for LTCF residents evaluated in the ED. Future interventions should strengthen communications between settings and across provider types, and address standardization of diagnostic and treatment communication pathways for LTCF residents with suspected infections transitioning between EDs and LTCFs.

Role of urine studies in asymptomatic febrile neutropenic patients presenting to the emergency department

BACKGROUND

The role of urine studies in the detection of urinary tract infection (UTI) in febrile neutropenic patients with urinary symptoms (having a urinary catheter or having a positive urine analysis) is inarguable. However, the evidence is scarce regarding the indication for urine studies in asymptomatic (i.e., without urinary symptoms) patients with febrile neutropenia (FN) presenting to the emergency department (ED). The aim of this study is to evaluate the need for obtaining urine studies in asymptomatic febrile neutropenic patients.

METHODS

This was a retrospective cohort study conducted on adult cancer patients who presented to the ED with FN and had no urinary symptoms. We included all ED presentations of eligible patients between January 2013 and September 2018. Student's t-test and Wilcoxon rank-sum test were used for continuous data, while Chi-square and Fisher's exact tests were used for categorical data. Participants were divided into two groups based on their urine culture (UC) results: negative and positive UCs. Two cut-offs were used for positive UC results: ≥10⁵ cfu/mL and ≥10⁴ cfu/mL.

RESULTS

We included 284 patients in our study. The age of our patient population was 48.5±18.5 years. More than two-thirds (68.7%) of patients had severe neutropenia, while only 3.9% and 9.9% of the patients had positive UCs at ≥10⁵ cfu/mL and ≥10⁴ cfu/mL, respectively. UCs were expectedly positive in most patients with urinalysis (UA) abnormalities. However, 27.3% and 32.1% of patients with positive UCs at ≥10⁵ cfu/mL and ≥10⁴ cfu/mL respectively had a normal UA.

CONCLUSIONS

In our study, the incidence of UTI in adult febrile neutropenic cancer patients who present to the ED without urinary symptoms is low. Consequently, routine urine testing may not be warranted in this population, as it adds unnecessary financial burdens on the patients and delays timely management.

Antibiotic prescribing and non-prescribing in nursing home residents with signs and symptoms ascribed to urinary tract infection (ANNA): study protocol for a cluster randomized controlled trial

BACKGROUND

Antibiotic overprescribing for suspected urinary tract infection (UTI) in nursing homes (NHs) is common. Typical clinical scenarios in which antibiotics are inappropriately prescribed include response to nonspecific signs and symptoms and/or a positive urine test in the absence of symptoms referable to the urinary tract. These and other scenarios for inappropriate antibiotic prescribing were addressed in a recent international Delphi study which resulted in the development of a decision tool for the empiric treatment of UTI in frail older adults. The aim of the current study is to implement this decision tool, by integrating it into the electronic health record (EHR) and providing education on its content and use, and to evaluate its effect on appropriate antibiotic prescribing. An additional aim is to evaluate the quality of the intervention and the implementation process.

METHODS

A cluster Randomized Controlled Trial (cRCT) is conducted in sixteen NHs and aims to include 897 residents diagnosed with suspected UTI. NHs in the intervention group use the EHR-integrated decision tool, and receive education for physicians and nursing staff; in the control group care as usual is provided. Data is collected through case report forms within the EHR at the day of diagnosis and at 3, 7, and 21 days thereafter. The primary outcome is appropriate antibiotic prescribing for suspected UTI at the day of diagnosis. Secondary outcomes include the course of symptoms, alternative diagnoses, treatment changes, complications, hospitalization, and mortality. Data on total antibiotic prescribing are additionally collected in the participating NHs 12 months before and during the study. Finally, the process evaluation combines cRCT data with questionnaires and qualitative interviews with NH professionals.

DISCUSSION

This is the first cRCT to evaluate the recently developed, international decision tool for empiric treatment of suspected UTI in NH residents. Study findings will elucidate the effect of the intervention on appropriate antibiotic prescribing for suspected UTI, and provide insight into the applicability of the decision tool in NHs in general and in specific subgroups of NH residents. With this study we aim to contribute to antibiotic stewardship efforts in long-term care.

TRIAL REGISTRATION

The ANNA study was registered at the Netherlands Trial Register on 26 February 2019, with identification number NTR NL7555 .

Subclinical bacteriuria and surgical site infections in dogs with cranial cruciate ligament disease

OBJECTIVE

To determine the prevalence of subclinical bacteriuria (SBU) in dogs with cranial cruciate ligament (CCL) disease, the clinical variables and clinicopathologic data associated with SBU, and the incidence of surgical site infections (SSI) in dogs with and without SBU.

STUDY DESIGN

Prospective, clinical cohort study.

ANIMALS

One hundred fifty-five dogs with CCL disease.

METHODS

Dogs had a urinalysis, sediment examination, and aerobic urine culture performed. Age, breed, sex, body weight, body condition score, clinical history, and physical examination findings were recorded. Dogs with SBU were not treated for bacteriuria or with postoperative antibiotics. Standard perioperative antimicrobials were provided for all dogs. Dogs that received nonsteroidal anti-inflammatory drugs were not excluded. Dogs that underwent an osteotomy were followed for at least 1 year to determine incidence of SSI. Outcomes and variables associated with SBU were assessed.

RESULTS

In 155 dogs with CCL disease, the prevalence of SBU was 6.5%, and SBU occurred exclusively in female dogs (11.4%). The incidence of SSI was 22.3% (25/112). Two of six dogs with SBU and 23/106 dogs without SBU developed SSI. Organisms isolated from SSI were different from those isolated from urine.

CONCLUSION

The prevalence of SBU in dogs with CCL disease was similar to that in other studies in which SBU was evaluated in various populations of dogs.

CLINICAL SIGNIFICANCE

Screening for and treatment of SBU may not be beneficial prior to tibial osteotomy for CCL disease. Additional studies are required to determine whether dogs with SBU have a greater risk of SSI.

Clinical Practice Guideline for the Management of Asymptomatic Bacteriuria: 2019 Update by the Infectious Diseases Society of America

Asymptomatic bacteriuria (ASB) is a common finding in many populations, including healthy women and persons with underlying urologic abnormalities. The 2005 guideline from the Infectious Diseases Society of America recommended that ASB should be screened for and treated only in pregnant women or in an individual prior to undergoing invasive urologic procedures. Treatment was not recommended for healthy women; older women or men; or persons with diabetes, indwelling catheters, or spinal cord injury. The guideline did not address children and some adult populations, including patients with neutropenia, solid organ transplants, and nonurologic surgery. In the years since the publication of the guideline, further information relevant to ASB has become available. In addition, antimicrobial treatment of ASB has been recognized as an important contributor to inappropriate antimicrobial use, which promotes emergence of antimicrobial resistance. The current guideline updates the recommendations of the 2005 guideline, includes new recommendations for populations not previously addressed, and, where relevant, addresses the interpretation of nonlocalizing clinical symptoms in populations with a high prevalence of ASB.

From Gene to Protein-How Bacterial Virulence Factors Manipulate Host Gene Expression During Infection

Bacteria evolved many strategies to survive and persist within host cells. Secretion of bacterial effectors enables bacteria not only to enter the host cell but also to manipulate host gene expression to circumvent clearance by the host immune response. Some effectors were also shown to evade the nucleus to manipulate epigenetic processes as well as transcription and mRNA procession and are therefore classified as nucleomodulins. Others were shown to interfere downstream with gene expression at the level of mRNA stability, favoring either mRNA stabilization or mRNA degradation, translation or protein stability, including mechanisms of protein activation and degradation. Finally, manipulation of innate immune signaling and nutrient supply creates a replicative niche that enables bacterial intracellular persistence and survival. In this review, we want to highlight the divergent strategies applied by intracellular bacteria to evade host immune responses through subversion of host gene expression via bacterial effectors. Since these virulence proteins mimic host cell enzymes or own novel enzymatic functions, characterizing their properties could help to understand the complex interactions between host and pathogen during infections. Additionally, these insights could propose potential targets for medical therapy.

Targeting Asymptomatic Bacteriuria in Antimicrobial Stewardship: the Role of the Microbiology Laboratory

This minireview focuses on the microbiologic evaluation of patients with asymptomatic bacteriuria, as well as indications for antibiotic treatment. Asymptomatic bacteriuria is defined as two consecutive voided specimens (preferably within 2 weeks) with the same bacterial species, isolated in quantitative counts of ≥10⁵ CFU/ml in women, including pregnant women; a single voided urine specimen with one bacterial species isolated in a quantitative count ≥10⁵ CFU/ml in men; and a single catheterized urine specimen with one or more bacterial species isolated in a quantitative count of ≥10⁵ CFU/ml in either women or men (or ≥10² CFU/ml of a single bacterial species from a single catheterized urine specimen). Any urine specimen with ≥10⁴ CFU/ml group B Streptococcus is significant for asymptomatic bacteriuria in a pregnant woman. Asymptomatic bacteriuria occurs, irrespective of pyuria, in the absence of signs or symptoms of a urinary tract infection. The two groups with the best evidence of adverse outcomes in the setting of untreated asymptomatic bacteriuria include pregnant women and patients who undergo urologic procedures with risk of mucosal injury. Screening and treatment of asymptomatic bacteriuria is not recommended in the following patient populations: pediatric patients, healthy nonpregnant women, older patients in the inpatient or outpatient setting, diabetic patients, patients with an indwelling urethral catheter, patients with impaired voiding following spinal cord injury, patients undergoing nonurologic surgeries, and nonrenal solid-organ transplant recipients. Renal transplant recipients beyond 1 month posttransplant should not undergo screening and treatment for asymptomatic bacteriuria. There is insufficient evidence to recommend for or against screening of renal transplant recipients within 1 month, patients with high-risk neutropenia, or patients with indwelling catheters at the time of catheter removal. Unwarranted antibiotics place patients at increased risk of adverse effects (including Clostridioides difficile diarrhea) and contribute to antibiotic resistance. Methods to reduce unnecessary screening for and treatment of asymptomatic bacteriuria aid in antibiotic stewardship.

Hyperthyroidism is not a risk factor for subclinical bacteriuria in cats: A prospective cohort study

Background

Subclinical bacteriuria is defined as a positive bacterial urine culture in the absence of clinical evidence of urinary tract infection (UTI). Studies have reported that hyperthyroid cats have UTIs (mostly subclinical) with prevalence rates of 12%‐22%. Consequently, clinicians consider hyperthyroidism a risk factor for development of subclinical bacteriuria, and many recommend urine culture when evaluating hyperthyroid cats.

Objectives

To compare the prevalence of subclinical bacteriuria (based on positive urine culture) in untreated hyperthyroid cats to that in euthyroid cats of similar age and sex.

Animals

Three hundred and ninety‐three hyperthyroid cats presented for radioiodine treatment and 131 euthyroid cats (≥7 years of age) presented for routine examination. Cats with signs of lower urinary tract disease were excluded.

Methods

Prospective cohort study. Both hyperthyroid and euthyroid cats had urine collected by cystocentesis for complete urinalysis and culture. Data pertaining to age, sex, body condition, and serum thyroxine and creatinine concentrations also were acquired. Logistic regression was performed to evaluate for potential risk factors for subclinical bacteriuria.

Results

Hyperthyroid cats showed a low prevalence of subclinical bacteriuria (4.3%), which did not differ from that found in euthyroid cats (4.6%). Of the signalment factors evaluated, only female sex was a significant risk factor (odds ratio [OR], 6.9; P = .002). Furthermore, positive urine cultures were more likely in specimens with dilute urine concentration (<1.035), pyuria, or microscopic bacteriuria.

Conclusions and Clinical Importance

Hyperthyroid cats are not at risk for subclinical bacteriuria. In the absence of lower urinary tract signs, no clinical benefit exists in routinely performing urine cultures when evaluating hyperthyroid cats.

UTI − quo vadis? New alternatives to treat uncomplicated urinary tract infections

Urinary tract infections (UTI) are one of the most common problems in urology clinics. The European Association of Urology (EAU) has been pioneering in its efforts to disseminate the latest clinical findings through the organization of the annual EAU congresses. At this year’s congress (EAU Barcelona 2019), various satellite symposia were organized, focusing on specific issues in the field of urology. "UTI − quo vadis? New alternatives to treat uncomplicated urinary tract infections" was one of the industry-sponsored symposia, organized with the aim of evaluating the current scenario and also throwing light on the paradigm shift in the treatment of acute, uncomplicated lower urinary tract infections (uUTI). Several interlinking topics were presented during this symposium. The topics covered antibiotic resistance, involving a presentation of the current data from the Global Prevalence Study on Infections in Urology (GPIU-study). This discussion was followed by case reports on the impact of antibiotic resistance on the management of patients with UTI/uUTI and treatment options for UTI/uUTI according to current guidelines. The highlight of the symposium was the presentation of very recent data from a gold standard phase III clinical trial (double-blind, double-dummy randomized study), demonstrating the non-inferiority of a herbal medicine (BNO 1045) versus antibiotic therapy (fosfomycin trometamol (FT), as a single dose = 3 g) for the treatment of acute, uncomplicated cystitis.

Gaps in communication between different staff groups and older adult patients foster unnecessary antibiotic prescribing for urinary tract infections in hospitals: a qualitative translation approach

Background

Studies have reported large scale overprescribing of antibiotics for urinary tract infection (UTI) in hospitalised older adults. Older adults often have asymptomatic bacteriuria, and clinicians have been found to diagnose UTIs inappropriately based on vague symptoms and positive urinalysis and microbiology. However, the joined perspectives of different staff groups and older adult patients on UTI diagnosis have not been investigated.

Methods

Thematic analysis of qualitative interviews with healthcare staff (n = 27) and older adult patients (n = 14) in two UK hospitals.

Results

Interviews featured a recurrent theme of discrepant understandings and gaps in communication or translation between different social groups in three key forms: First, between clinicians and older adult patients about symptom recognition. Second, between nurses and doctors about the use and reliability of point-of-care urinary dipsticks. Third, between nurses, patients, microbiologists and doctors about collection of urine specimens, contamination of the specimens and interpretation of mixed growth laboratory results. The three gaps in communication could all foster inappropriate diagnosis and antibiotic prescribing.

Conclusion

Interventions to improve diagnosis and prescribing for UTIs in older adults typically focus on educating clinicians. Drawing on the sociological concept of translation and interviews with staff and patients our findings suggest that inappropriate diagnosis and antibiotic prescribing in hospitals can be fuelled by gaps in communication or translation between different staff groups and older adult patients, using different languages and technologies or interpreting them differently. We suggest that interventions in this area may be improved by also addressing discrepant understandings and communication about symptoms, urinary dipsticks and the process of urinalysis.

Impact of syndrome-specific antimicrobial stewardship interventions on use of and resistance to fluoroquinolones: An interrupted time series analysis

BACKGROUND

Fluoroquinolones are often prescribed unnecessarily and are an important risk factor for infection with fluoroquinolone-resistant gram-negative bacilli and Clostridioides difficile.

METHODS

We conducted a quasi-experimental study to determine the impact of sequential syndrome-specific stewardship interventions on use of and resistance to fluoroquinolones in a tertiary care hospital. An initial 2-year intervention focused on reducing treatment of asymptomatic bacteriuria and ensuring concordance of urinary tract infection treatment with guidelines. A second 5-year intervention focused on limiting overuse of fluoroquinolones for health care-associated pneumonia in conjunction with a formal stewardship program. The primary outcomes were fluoroquinolone use and changes in use over time analyzed by segmented regression analysis.

RESULTS

The asymptomatic bacteriuria and urinary tract infection intervention resulted in a significant reduction in fluoroquinolone use, with a significant change from an increasing to a decreasing rate of use (change in slope of quarterly defined daily doses/1,000 patient days -15.3, P < .01). The health care-associated pneumonia intervention resulted in a continued significant reduction in fluoroquinolone use (rate ratio = 0.68, P < .01). During the interventions, fluoroquinolone susceptibility increased significantly in Pseudomonas aeruginosa, but not in Escherichia coli, Klebsiella spp., or C difficile.

CONCLUSIONS

Antimicrobial stewardship interventions focused on specific syndromes may be effective in reducing fluoroquinolone use. In our hospital, reduction in fluoroquinolone use resulted in increased fluoroquinolone susceptibility in P aeruginosa, but not other Enterobacteriaceae or C difficile.

Elevated urine IL-10 concentrations associate with Escherichia coli persistence in older patients susceptible to recurrent urinary tract infections

Background

Age is a significant risk factor for recurrent urinary tract (rUTI) infections, but the clinical picture is often confused in older patients who also present with asymptomatic bacteriuria (ASB). Yet, how bacteriuria establishes in such patients and the factors underpinning and/or driving symptomatic UTI episodes are still not understood. To explore this further a pilot study was completed in which 30 male and female community based older patients (mean age 75y) presenting clinically with ASB / rUTIs and 15 control volunteers (72y) were recruited and monitored for up to 6 months. During this period symptomatic UTI episodes were recorded and urines collected for urinary cytokine and uropathogenic Escherichia coli (UPEC) analyses.

Results

Eighty-six per cent of patients carried E. coli (10² ≥ 10⁵ CFU/ml urine) at some point throughout the study and molecular typing identified 26 different E. coli strains in total. Analyses of urine samples for ten different cytokines identified substantial patient variability. However, when examined longitudinally the pro-inflammatory markers, IL-1 and IL-8, and the anti-inflammatory markers, IL-5 and IL-10, were significantly different in the patient urines compared to those of the controls (P < 0.0001). Furthermore, analysing the cytokine data of the rUTI susceptible cohort in relation to E. coli carriage, showed the mean IL-10 concentration to be significantly elevated (P = 0.04), in patients displaying E. coli numbers ≥10⁵ CFU/ml.

Conclusions

These pilot study data suggest that bacteriuria, characteristic of older rUTI patients, is associated with an immune homeostasis in the urinary tract involving the synthesis and activities of the pro and anti-inflammatory cytokines IL-1, IL-5, IL-8 and IL-10. Data also suggests a role for IL-10 in regulating bacterial persistence.

Evidence-Informed Practice: Diagnostic Questions in Urinary Tract Infections in the Elderly

Introduction

Routine interventions in the practice of medicine often lack definitive evidence or are based on evidence that is either not high quality or of only modest-to-marginal effect sizes. An abnormal urinalysis in an elderly patient presenting to the emergency department (ED) with non-specific symptoms represents one condition that requires an evidence-informed approach to diagnosis and management of either asymptomatic bacteriuria or urinary tract infection (UTI). The emergency provider often will not have access to urine cultures, and the risks associated with antibiotic use in the elderly are not without potentially significant side effects.

Methods

We performed a historical and clinical review of the growing body of literature suggesting measurable differences in the systemic immune response manifest among patients with asymptomatic pyuria and UTI, including increases in the pro-inflammatory cytokine interleukin-6 and the acute phase reactant procalcitonin.

Results

Serum procalcitonin, a peptide that undergoes proteolysis into calcitonin, has been demonstrated to quickly and reliably rise in patients with severe bacterial infections, and may serve as a potentially sensitive and specific marker for identification of bacterial illness.

Conclusion

In the absence of validated risk scores for diagnosing UTI in elderly patients presenting to the ED, there may be a role for the use of procalcitonin in this patient population.

Ibuprofen lacks direct antimicrobial properties for the treatment of urinary tract infection isolates

The high incidence of urinary tract infection (UTI) among women and children, in combination with a lack of antibiotic efficacy with regard to pathogen eradication and recurrence prevention, as well as the negative side effects associated with antibiotics, has led researchers to explore the role of non-steroidal anti-inflammatory drugs as a primary management strategy. The aim of this study was to determine whether ibuprofen (IBU) or one of its major metabolites, 2-carboxyibuprofen (CIBU), could affect the growth and adhesion of the two most common uropathogens, Escherichia coli and Enterococcus faecalis. The bacterial growth and adhesion to the urothelial cells of E. coli UTI89 and E. faecalis 1131 in the presence of physiologically relevant concentrations of IBU and CIBU were assessed. The effect of IBU on bacterial adhesion to urothelial cells was also assessed following exposure to trimethoprim/sulfamethoxazole (TMP/SMX) and nitrofurantoin. Bacterial growth was not affected by IBU. Further, only at high levels of IBU not regularly found in the bladder was there a significant increase in E. faecalis 1131 attachment at growth inhibitory concentrations of TMP/SMX. There was no effect on the attachment of E. faecalis or E. coli to urothelial cells in the presence of nitrofurantoin. These studies indicate that the beneficial effects of IBU for UTI management are likely mediated through its anti-inflammatory properties rather than direct interactions with uropathogens in the bladder.

Fimbriae reprogram host gene expression - Divergent effects of P and type 1 fimbriae

Pathogens rely on a complex virulence gene repertoire to successfully attack their hosts. We were therefore surprised to find that a single fimbrial gene reconstitution can return the virulence-attenuated commensal strain Escherichia coli 83972 to virulence, defined by a disease phenotype in human hosts. E. coli 83972pap stably reprogrammed host gene expression, by activating an acute pyelonephritis-associated, IRF7-dependent gene network. The PapG protein was internalized by human kidney cells and served as a transcriptional agonist of IRF-7, IFN-β and MYC, suggesting direct involvement of the fimbrial adhesin in this process. IRF-7 was further identified as a potent upstream regulator (-log (p-value) = 61), consistent with the effects in inoculated patients. In contrast, E. coli 83972fim transiently attenuated overall gene expression in human hosts, enhancing the effects of E. coli 83972. The inhibition of RNA processing and ribosomal assembly indicated a homeostatic rather than a pathogenic end-point. In parallel, the expression of specific ion channels and neuropeptide gene networks was transiently enhanced, in a FimH-dependent manner. The studies were performed to establish protective asymptomatic bacteriuria in human hosts and the reconstituted E. coli 83972 variants were developed to improve bacterial fitness for the human urinary tract. Unexpectedly, P fimbriae were able to drive a disease response, suggesting that like oncogene addiction in cancer, pathogens may be addicted to single super-virulence factors.

Urinary tract infections affect millions of individuals annually, and many patients suffer from recurring infections several times a year. Antibiotic resistance is increasing rapidly and new strategies are needed to treat even these common bacterial infections. One approach is to use the protective power of asymptomatic bacterial carriage, which has been shown to protect the host against symptomatic urinary tract infection. Instilling “nice” bacteria in the urinary bladder is therefore a promising alternative approach to antibiotic therapy. In an effort to increase the therapeutic use of asymptomatic bacteriuria, we reintroduced bacterial adhesion molecules into the therapeutic Escherichia coli strain 83972 and inoculated patients who are in need of alternative therapy. To our great surprise, the P fimbriated variant caused symptoms, despite lacking other virulence factors commonly thought to be necessary to cause disease. In contrast, type 1 fimbriae, did not provoke symptoms but enhanced the beneficial properties of the wild-type strain. This is explained by a divergent effect of these fimbrial types on host gene expression, where P fimbriae activate the IRF-7 transcription factor that regulates pathology in infected kidneys, suggesting that a single, potent virulence gene may be sufficient to create virulence in human hosts.

Overprescribing antibiotics for asymptomatic bacteriuria in older adults: a case series review of admissions in two UK hospitals

Background

Overdiagnosis and overtreatment of urinary tract infection (UTI) with antibiotics is a concern. In older adults, diagnosis of UTI using near-patient urine tests (reagent strip tests, dipsticks) is advised against because the age-related increase in asymptomatic bacteriuria can cause false-positive results. Instead, UTI diagnosis should be based on a full clinical assessment. Previous research lacks systematic information on urine dipstick use in hospitals. The aim of this study was to examine the use of urine dipstick tests and microbiology among older adult hospital admissions in relation to recommended UTI diagnostic criteria. A further aim was to assess factors associated with the use of dipsticks.

Methods

A case series review of patients aged ≥70 years admitted to two NHS Trust hospitals in England. Records from 312 patients admitted in 2015 meeting inclusion criteria were selected at random.

Results

Of 298 complete patient records, 54% had at least one urine dipstick test recorded. 13% (21/161) of patients who received a urine dipstick test were diagnosed as having a UTI, only 2 out of these 21 cases had two or more clinical signs and symptoms. 60 patients received a second dipstick test, leading to 13 additional cases of UTI diagnosis. Dipstick tests were more likely to be performed on patients with a history of falls (OR 1.93, 95% CI:1.21, 3.07, p < 0.01), and less likely on those with dementia (OR 0.44, 95% CI: 0.22, 0.87, p < 0.05). The most common reason for testing was routine admissions policy (49.1% of cases), but these cases were predominantly in one hospital.

Conclusions

Use of urine dipstick tests was high among older adults admitted to hospitals. Most cases were asymptomatic and therefore received inappropriate antibiotic therapy. This paper highlights the need to implement new Public Health England diagnostic guidelines to hospital admission and emergency departments.

Urine cultures in a long-term care facility (LTCF): time for improvement

Background

Urinary tract infections (UTIs) are the most prevalent infections in long-term care facilities (LTCFs). Numerous studies have described the problem of inadequate UTI diagnosis and treatment. We assessed the role of urine cultures in the diagnosis and treatment of UTIs in a LTCF.

Methods

In a 370-bed non-academic LTCF a retrospective assessment of antibiotic (AB) prescriptions for UTIs and urine cultures was performed from July 2014 to January 2016. The reasons why physicians, including 11 nursing home physicians and 2 junior doctors, ordered urine cultures were recorded using questionnaires.

Results

During the study period, 378 residents were prescribed 1672 AB courses; 803 were for UTIs. One hundred and fifty-five urine cultures were obtained from 135 residents; 66 of these cultures were performed on the same day as ABs were prescribed (8% of all prescriptions for UTI), while 89 were not. There was a discrepancy between the actions that seemed logical based on the culture results and the actions that were actually taken in 75% of the cases. In these cases, initial AB treatment was not adjusted when the isolated microorganism was resistant to the AB prescribed, the urine culture was positive and no ABs had previously been administered, or ABs were prescribed and no microorganism was isolated.

The most frequent reason for ordering a urine culture was to confirm the diagnosis of a UTI.

Conclusion

In the majority of patients, AB therapy was not adjusted when the urine culture results suggested it may be appropriate. The physicians were erroneously convinced that UTIs could be diagnosed by a positive urine culture.

Electronic supplementary material

The online version of this article (10.1186/s12877-018-0909-x) contains supplementary material, which is available to authorized users.

Enterococcus faecalis persistence in pediatric patients treated with antibiotic prophylaxis for recurrent urinary tract infections

Aim: Enterococcus faecalis is one of the most common causes of recurrent urinary tract infection (RUTI), yet enterococcal pathogenesis is poorly understood. Our aims were to identify the prevalence of enterococci in RUTI patients and characterize the enterococcal response to nitrofurantoin and trimethoprim-sulfamethoxazole. Materials & methods: We studied pediatric patients receiving antibiotic prophylaxis and those only under clinical observation for 12 months (n = 39). We then assessed the response of uropathogenic E. faecalis to nitrofurantoin and trimethoprim–sulfamethoxazole. Results: Enterococci were isolated from almost half of patients and exposure of Enterococcus to nitrofurantoin increased virulence properties; this did not correlate with increased expression of virulence factors. Conclusion: Our results demonstrate that antibiotic prophylaxis may not be suitable for treatment of enterococcal RUTI (NCT02357758).

Outcomes of Urinary Tract Infection Management by Pharmacists (RxOUTMAP): A study of pharmacist prescribing and care in patients with uncomplicated urinary tract infections in the community

Background

Pharmacists have the authorization to prescribe medications for the treatment of uncomplicated urinary tract infections (UTI) in some provinces. However, there are limited data on the outcomes of this care by pharmacists. Our objective was to evaluate the effectiveness, safety and patient satisfaction with pharmacist prescribing and care in patients with uncomplicated UTI.

Methods

We conducted a prospective registry trial in 39 community pharmacies in the Canadian province of New Brunswick. Adult patients were enrolled if they presented to the pharmacy with either symptoms of UTI with no current antibacterial treatment (Pharmacist-Initial Arm) or if they presented with a prescription for an antibacterial to treat UTI from another health care provider (Physician-Initial Arm). Pharmacists assessed patients and if they had complicating factors or red flags for systemic illness or pyelonephritis, they were excluded from the study. Pharmacists either prescribed antibacterial therapy, modified antibacterial therapy, provided education only or referred to physician, as appropriate. The primary outcome was clinical cure at 2 weeks and the secondary outcomes included adverse events and patient satisfaction.

Results

A total of 750 patients were enrolled (87.4% in the Pharmacist-Initial Arm), average age was 40.9 (SD 16.0) years. Clinical cure was achieved in 88.9% of patients. Of those that did not have sustained symptom resolution, most (5.5% overall) had symptom recurrence after completion of therapy. Adverse events were reported by 7.2% of patients and 88.9% of those continued their medication. Most adverse events were gastrointestinal-related and transient. The patient satisfaction survey reflected very high levels of satisfaction for the care they received, as well as for trust and accessibility of the pharmacist.

Conclusion

Pharmacist management of uncomplicated UTI is effective, safe, and patient satisfaction appears very high.

Prevalence of feline urinary tract pathogens and antimicrobial resistance over five years

The aim of this retrospective study was to document the prevalence of bacterial species in cats with significant bacteriuria and to compare their antimicrobial susceptibilities over five years. One hundred sixty-nine positive urine cultures from 150 cats were included. Fifty-five per cent showed clinical signs, while 40 per cent had subclinical bacteriuria. Escherichia coli, Staphylococcus species, Enterococcus species, Streptococcus species and Proteus mirabilis accounted for 50.5 per cent, 22.9 per cent, 15,1 per cent, 3.6 per cent and 2.6 per cent, respectively. Enterococcus species was significantly more common in cats with subclinical bacteriuria. Enterococcus species and Proteus mirabilis isolates were resistant to a significantly higher number of antimicrobials than other isolates. Applying the formula to select rational antimicrobial therapy, bacterial isolates were most likely to be susceptible to imipenem, nitrofurantoin, gentamicin and amoxicillin clavulanic acid. Over the study period, only minor differences were noted for the antimicrobial impact factors (IFs) between years and between cats with and without clinical signs. The cumulative IF increased significantly compared with the previous 10 years. Empirical treatment of bacterial cystitis should be avoided whenever possible and, if needed, based on the locally determined bacterial spectrum and antibiotic susceptibility.

Clinical Practice Guidelines for the Antibiotic Treatment of Community-Acquired Urinary Tract Infections

Urinary tract infections (UTIs) are infectious diseases that commonly occur in communities. Although several international guidelines for the management of UTIs have been available, clinical characteristics, etiology and antimicrobial susceptibility patterns may differ from country to country. This work represents an update of the 2011 Korean guideline for UTIs. The current guideline was developed by the update and adaptation method. This clinical practice guideline provides recommendations for the diagnosis and management of UTIs, including asymptomatic bacteriuria, acute uncomplicated cystitis, acute uncomplicated pyelonephritis, complicated pyelonephritis related to urinary tract obstruction, and acute bacterial prostatitis. This guideline targets community-acquired UTIs occurring among adult patients. Healthcare-associated UTIs, catheter-associated UTIs, and infections in immunocompromised patients were not included in this guideline.