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.

Antibiotic utilization and symptom improvement in a retrospective cohort of women with urinary tract infection symptoms

INTRODUCTION AND HYPOTHESIS

Urinary tract infections (UTIs) are one of the most common bacterial infections in women. We hypothesized that over half of those treated empirically would receive inappropriate antibiotics, those treated expectantly would have lower symptom improvement without antibiotics, and that overall progression to sequelae would be uncommon.

METHODS

In this retrospective cohort study of women with UTI symptoms, we quantified the proportion who received inappropriate antibiotics in those treated empirically, defined as those with a negative urine culture or antibiotics that were changed according to culture sensitivities, and identified factors associated with symptom improvement during expectant management. Secondarily, we sought to determine the proportion of UTI sequelae in both groups. During the study time frame, a modified UTI Symptom Assessment (UTISA) questionnaire was administered at baseline and again, with a global rating for change instrument, when urine culture results were relayed.

RESULTS

Analyses included 152 women, mean age 66.5 (SD 15.0) years, 30 (20%) received empiric antibiotics, and 122 (80%) expectant management. At baseline, the empiric group reported greater mean scores for dysuria (p < 0.01), urgency (p < 0.01), frequency (p < 0.01), and incomplete emptying (p < 0.01). Positive culture results were reported for 16 (53%) in the empiric group and 72 (59%) in the expectant group. Inappropriate antibiotics were prescribed to 18 (60%) of the empiric group. A negative urine culture was associated with improvement in symptoms in the expectant group. No subjects experienced UTI sequelae within 30 days of initial evaluation.

CONCLUSION

In our cohort of older women with UTI symptoms, deferring antibiotics until urine culture  resulted appeared to be safe and decreased the use of inappropriate antibiotics.

Surgical treatment of stress urinary incontinence: comparison of robotic-assisted Burch urethropexy with retropubic midurethral sling

Synthetic retropubic midurethral slings (RMUS) and robotic-assisted Burch urethropexies (RA-Burch) are common surgical treatment options for stress urinary incontinence (SUI). Few data exist comparing the success of these two retropubic surgeries. This retrospective cohort study of RA-Burch and RMUS procedures compared the proportion of patients with subjective cure after RA-Burch compared to RMUS at our institution between 2016 and 2020. Subjective cure was defined as reporting no symptoms of SUI at longest follow-up. Chi-square, Fisher's exact, Mann-Whitney U tests, logistic regression, and Kaplan-Meier log-rank tests were used in analyses. The overall cohort of 235 subjects included 47 RA-Burch cases matched 1:4 with 188 RMUS cases. Patients who underwent RA-Burch were younger (p < .01), had lower BMIs (p = .04), and were more likely to have concomitant procedures, including hysterectomy (p < .01). There was no difference in subjective cure at longest follow-up (p = .76). Median follow-up was longer in the RA-Burch group (p < .01). There was no difference in early postoperative complications, EBL, treatment for persistent SUI, or new urge urinary incontinence at longest follow-up. Both groups experienced postoperative urinary retention at a similar rate, although 4 RMUS patients required sling lysis and one patient experienced a mesh exposure. Patients undergoing RA-Burch had significantly longer OR times when no concomitant procedure was performed (p < .01). There were no significant predictors of SUI recurrence when controlling for baseline variables. This study suggests that RA-Burch and RMUS may be equally efficacious for patients with symptoms of SUI desiring surgical management.

Microbial Interactions in the Phyllosphere Increase Plant Performance under Herbivore Biotic Stress

The phyllosphere supports a tremendous diversity of microbes and other organisms. However, little is known about the colonization and survival of pathogenic and beneficial bacteria alone or together in the phyllosphere across the whole plant life-cycle under herbivory, which hinders our ability to understand the role of phyllosphere bacteria on plant performance. We addressed these questions in experiments using four genetically and biogeographically diverse accessions of Arabidopsis thaliana, three ecologically important bacterial strains (Pseudomonas syringae DC3000, Xanthomonas campestris, both pathogens, and Bacillus cereus, plant beneficial) under common garden conditions that included fungus gnats (Bradysia spp.). Plants supported greater abundance of B. cereus over either pathogenic strain in the phyllosphere under such greenhouse conditions. However, the Arabidopsis accessions performed much better (i.e., early flowering, biomass, siliques, and seeds per plant) in the presence of pathogenic bacteria rather than in the presence of the plant beneficial B. cereus. As a group, the plants inoculated with any of the three bacteria (Pst DC3000, Xanthomonas, or Bacillus) all had a higher fitness than uninoculated controls under these conditions. These results suggest that the plants grown under the pressure of different natural enemies, such as pathogens and an herbivore together perform relatively better, probably because natural enemies induce host defense against each other. However, in general, a positive impact of Bacillus on plant performance under herbivory may be due to its plant-beneficial properties. In contrast, bacterial species in the mixture (all three together) performed poorer than as monocultures in their total abundance and host plant growth promotion, possibly due to negative interspecific interactions among the bacteria. However, bacterial species richness linearly promoted seed production in the host plants under these conditions, suggesting that natural enemies diversity may be beneficial from the host perspective. Collectively, these results highlight the importance of bacterial community composition on plant performance and bacterial abundance in the phyllosphere.

ATP-dependent binding cassette transporter G family member 16 increases plant tolerance to abscisic acid and assists in basal resistance against Pseudomonas syringae DC3000

Plants have been shown previously to perceive bacteria on the leaf surface and respond by closing their stomata. The virulent bacterial pathogen Pseudomonas syringae pv tomato DC3000 (PstDC3000) responds by secreting a virulence factor, coronatine, which blocks the functioning of guard cells and forces stomata to reopen. After it is inside the leaf, PstDC3000 has been shown to up-regulate abscisic acid (ABA) signaling and thereby suppress salicylic acid-dependent resistance. Some wild plants exhibit resistance to PstDC3000, but the mechanisms by which they achieve this resistance remain unknown. Here, we used genome-wide association mapping to identify an ATP-dependent binding cassette transporter gene (ATP-dependent binding cassette transporter G family member16) in Arabidopsis (Arabidopsis thaliana) that contributes to wild plant resistance to PstDC3000. Through microarray analysis and β-glucuronidase reporter lines, we showed that the gene is up-regulated by ABA, bacterial infection, and coronatine. We also used a green fluorescent protein fusion protein and found that transporter is more likely to localize on plasma membranes than in cell walls. Transferred DNA insertion lines exhibited consistent defective tolerance of exogenous ABA and reduced resistance to infection by PstDC3000. Our conclusion is that ATP-dependent binding cassette transporter G family member16 is involved in ABA tolerance and contributes to plant resistance against PstDC3000. This is one of the first examples, to our knowledge, of ATP-dependent binding cassette transporter involvement in plant resistance to infection by a bacterial pathogen. It also suggests a possible mechanism by which plants reduce the deleterious effects of ABA hijacking during pathogen attack. Collectively, these results improve our understanding of basal resistance in Arabidopsis and offer unique ABA-related targets for improving the innate resistance of plants to bacterial infection.