Prospective randomized comparison of therapy and no therapy for asymptomatic bacteriuria in institutionalized elderly women
Abstract
Fifty elderly (mean age, 83.4 ± 8.8 years) institutionalized women with asymptomatic bacteriuria were randomly assigned either to receive therapy for treatment of all episodes of bacteriuria identified on monthly culture or to receive no therapy unless symptoms developed. Subjects were followed for one year. The therapy group had a mean monthly prevalence of bacteriuria 31 ± 15 percent lower than those in the no-therapy group, but periods free of bacteriuria lasting six months or longer were documented for only five (24 percent) subjects. For residents receiving no therapy, 71 percent showed persistent infection with the same organism(s). Antimicrobial therapy was associated with an increased incidence of reinfection (1.67 versus 0.87 per patient-year) and adverse antimicrobial drug effects (0.51 versus 0.046 per patient-year) as well as isolation of increasingly resistant organisms in recurrent infection when compared with no therapy. No differences in genitourinary morbidity or mortality were observed between the groups. Thus, despite a lowered prevalence of bacteriuria, no short-term benefits were identified and some harmful effects were observed with treatment of asymptomatic bacteriuria. These data support current recommendations of no therapy for asymptomatic bacteriuria in this population.
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Correlation of Pyuria and Bacteriuria in Acute Care
2022, American Journal of MedicinePyuria is often used as an import marker in the diagnosis of urinary tract infection. The interpretation of pyuria may be especially important in patients with nonspecific complaints. There is a paucity of data to demonstrate the utility of pyuria alone in the diagnosis of bacteriuria or urinary tract infection. This study aims to further define the relationship of pyuria and positive bacterial growth in urine culture, as well as the diagnostic utility of different urine white blood cell cutoff points.
A total of 46,127 patients older than the age of 18 were selected from the inpatient population of HCA Healthcare System Capital Division. Urine microscopy results were stratified by white blood cell count and correlated with positivity of urine culture bacterial growth. The optimal urine white blood cell cutoff was derived based on the receiver operating characteristic curve plot.
Urine microscopy finding of white blood cell 0-5 cell/hpf, 5-10 cell/hpf, 10-25 cell/hpf, and higher than 25 cell/hpf was associated with 25.4%, 28.2%, 33%, and 53.8% rates of bacteriuria, respectively. The receiver operating characteristic curve plot demonstrated that pyuria alone did not provide adequate diagnostic accuracy to predict bacteriuria. The optimal cutoff point for the best combination of sensitivity and specificity was found to be 25 cell/hpf.
Pyuria alone provides inadequate diagnostic accuracy for predicting bacteriuria. Urine white blood cell count greater than 25 cell/hpf was found to be the optimal cutoff to detect bacteriuria. The result of this study supports the current guideline recommendation against antibiotic treatment based on urine analysis alone. It also informs future design of randomized controlled trial that investigates interventional strategies for patients with pyuria and nonspecific complaints.
Carbapenem resistance associated with coliuria among outpatient and hospitalised urology patients
2022, New Microbes and New InfectionsThe World Health Organization in 2017 listed carbapenem resistant Enterobacteriaceae (CRE) with critical priority for research. A research to assess carbapenem resistant Escherichia coli (CREc) in coliuria among the outpatients and inpatients of a tertiary health institution was carried out using conventional methods, polymerase chain reaction, Sanger sequencing, and bioinformatics. There were 39 positive coliuria cases from the urine samples collected from a total of 126 patients with various genitourinary diseases. The E. coli enumeration (log10 CFU/mL) revealed that 82.1% (n = 32) of the samples showed significant coliuria, 12.8% (n = 5) showed non-significant coliuria while 5.1% (n = 2) showed indeterminate coliuria even when repeated. Significantly higher numbers (p > 0.05) of the sampled inpatients yielded positive coliuria (57.9%) than the outpatients. Though there were significantly more (P > 0.05) urology female patients (n = 77) than male (n = 49), coliuria was more prevalent in sampled male patients (34.9%) than female (28.6%). Highest prevalence of coliuria was observed among the age range (18–30) years. Selected CREc that was sequenced and the sequences submitted to GenBank of National Center for Biotechnological Information (NCBI) were Escherichia coli AYO-WINI111 and Escherichia coli AYO-WINI112 with accession number MT735391 and MT735392, respectively. High resistance was observed against ertapenem (53%), imipenem (62%), meropenem (48%), and doripenem (47%), while 7%–22% of the isolates showed phenotypic intermediate carbapenem resistance. Critically dangerous CREc are harboured by large number urology patients in the study area, depicting the need for more attention in the management of the condition, as CREc are close to achieving totally antibiotic resistance.
Urinary tract infections and multiple sclerosis: Recommendations from the French Multiple Sclerosis Society
2020, Revue NeurologiqueCitation Excerpt :Very little literature is available concerning the management of ABU (colonization) exclusively in MS. So, evaluation of the literature was extended to studies concerning the general population (elderly patients) as well as populations of patients with neurologic bladder in the case of spinal cord injury. The treatment of ABU of elderly institutionalized patients did not modify the morbidity-mortality but increased the emergence of multidrug-resistant bacteria [115,116]. ABU in cases of neurologic bladder was studied mainly with respect to self-intermittent catheterization of patients with spinal cord injury and the prevalence was high, reaching sometimes 89% [103].
Establish recommendations for the management of UTIs in MS patients.
Urinary tract infections (UTIs) are common during multiple sclerosis (MS) and are one of the most common comorbidities potentially responsible for deaths from urinary sepsis.
The recommendations attempt to answer three main questions about UTIs and MS. The French Group for Recommendations in MS (France4MS) did a systematic review of articles from PubMed and universities databases (01/1980–12/2019). The RAND/UCLA appropriateness method, which has been developed to synthesize the scientific literature and expert opinions on health care topics, was used for reaching a formal agreement. 26 MS experts worked on the full-text review and a group of 70 multidisciplinary health care specialists validated the final evaluation of summarized evidences.
UTIs are not associated with an increased risk of relapse and permanent worsening of disability. Only febrile UTIs worsen transient disability through the Uhthoff phenomenon. Some immunosuppressive treatments increase the risk of UTIs in MS patients and require special attention especially in case of hypogammaglobulinemia. Experts recommend to treat UTIs in patients with MS, according to recommendations of the general population. Prevention of recurrent UTIs requires stabilization of the neurogenic bladder. In some cases, weekly oral cycling antibiotics can be proposed after specialist advice. Asymptomatic bacteriuria should not be screened for or treated systematically except in special cases (pregnancy and invasive urological procedures).
Physicians and patients should be aware of the updated recommendations for UTis and MS.
Clinical presentation and performance of urine dipstick for diagnosis of urinary infection in geriatric population
2019, Revue de Medecine InterneL’infection urinaire (IU) constitue la deuxième cause d’infection bactérienne communautaire chez le sujet âgé. Ce diagnostic est difficile car les symptômes sont souvent atypiques. Nous présentons les caractéristiques des patients ayant une IU parmi une population gériatrique (signes fonctionnels urinaires et/ou syndrome infectieux). Nous avons également évalué la sensibilité et la spécificité de la bandelette urinaire (BU) pour le diagnostic d’IU dans cette population.
Nous avons réalisé une étude observationnelle, prospective, monocentrique, d’avril 2017 à janvier 2018, incluant tous les patients hospitalisés en gériatrie, présentant des signes fonctionnels urinaires et/ou un syndrome infectieux sans point d’appel, pour lesquels un examen cytobactériologique des urines (ECBU) a été demandé. Une BU était systématiquement réalisée pour tous ces patients.
Les caractéristiques cliniques et biologiques des patients ont été étudiées selon le diagnostic définitif. En outre, les résultats des BU ont été comparés à ceux des ECBU en cas de diagnostic final d’IU.
Au total, 165 patients ont été inclus. Parmi eux, 67 (40,6 %) avaient une IU et 98 (59,4 %) avaient un autre diagnostic. Il y avait significativement plus de femmes (p < 0,05), et des scores de MMSE plus bas (p < 0,05) dans la population qui présentait une IU.
La BU présentait une sensibilité élevée (92 %) et une VPN élevée (91 %) intéressantes dans notre population.
En cas d’IU chez le sujet âgé, peu de critères sont discriminants avec une autre origine. Par ailleurs, une BU négative suggère l’absence d’IU en raison de sa bonne valeur prédictive négative.
Urinary tract infections (UTI) are the second cause of community-acquired bacterial infections in the elderly. Distinguishing symptomatic UTI from asymptomatic bacteriuria is problematic, as older adults are less likely to present with localized urinary symptoms. We evaluated characteristics of patients presenting UTI among elderly with sepsis. Moreover, we aimed to evaluate the sensibility and specificity of urine dipstick tests in the diagnosis of UTI in geriatric population.
We led a prospective, monocentric, observational study between April 2017 and January 2018. We included patients hospitalized in geriatric wards, who were prescribed urine culture for UTI symptoms or/and infection without primary sites for which a urine culture was prescribed. Dipstick urinalyses were performed for all patients.
Clinical and biological characteristics of all patients were compared according to the final diagnosis of UTI. Moreover, results of dipstick tests were evaluated for the diagnosis of UTI in this population.
Among 165 patients, 67 (40.6 %) had a UTI and 98 (59.4 %) had another diagnosis. These two groups were comparable for age and daily-living activities. In the UTI group, the proportion of women was higher than in the other group (P < 0.05), and mean MMSE score was lower (P < 0.05).
Positive urine dipstick test for leukocytes and/or nitrites had high sensitivity (92 %), but low specificity (50 %). Negative predictive value of this test was high (91 %).
For suspicion of UTI among elderly, few criteria are specific. Negative dipstick tests can suggest an absence of UTI due to its high negative predictive value.
Effectiveness of behavioural interventions to reduce urinary tract infections and Escherichia coli bacteraemia for older adults across all care settings: a systematic review
2019, Journal of Hospital InfectionEscherichia coli bacteraemia rates in the UK have risen; rates are highest among older adults. Previous urinary tract infections (UTIs) and catheterization are risk factors.
To examine effectiveness of behavioural interventions to reduce E. coli bacteraemia and/or symptomatic UTIs for older adults.
Sixteen databases, grey literature, and reference lists were searched. Titles and/or abstracts were scanned and selected papers were read fully to confirm suitability. Quality was assessed using Critical Appraisal Skills Programme guidelines and Scottish Intercollegiate Guidelines Network grading.
Twenty-one studies were reviewed, and all lacked methodological quality. Six multi-faceted hospital interventions including education, with audit and feedback or reminders reduced UTIs but only three supplied statements of significance. One study reported decreasing catheter-associated UTI (CAUTI) by 88% (F (1,20) = 7.25). Another study reported reductions in CAUTI from 11.17 to 10.53 during Phase I and by 0.39 during Phase II (χ2 = 254). A third study reported fewer UTIs per patient week (risk ratio = 0.39). Two hospital studies of online training and catheter insertion and care simulations decreased CAUTIs from 33 to 14 and from 10.40 to 0. Increasing nursing staff, community continence nurses, and catheter removal reminder stickers reduced infection. There were no studies examining prevention of E. coli bacteraemias.
The heterogeneity of studies means that one effective intervention cannot be recommended. We suggest that feedback should be considered because it facilitated reductions in UTI when used alone or in multi-faceted interventions including education, audit or catheter removal protocols. Multi-faceted education is likely to be effective. Catheter removal protocols, increased staffing, and patient education require further evaluation.
Prospective evaluation of the management of urinary tract infections in 134 French nursing homes
2018, Medecine et Maladies InfectieusesProspective assessment of the management of urinary tract infections (UTI) in the nursing homes of the Hauts-de-France region.
A 50-question form had to be filled in for up to five consecutive residents treated for UTI in each nursing home. If necessary, diagnoses were reclassified according to the 2014 French Infectious Diseases Society guidelines. Analyses were presented per supposed (reported) and reclassified diagnoses.
Of 397 contacted facilities, 134 participated and informed 444 UTI episodes. Reported diagnostic criteria were burning urination (32%), malodorous urine (29%), confusion (28%), and turbid urine (19%). Twenty-one percent of diagnoses were based on erroneous criteria. Less than 50% of residents had a urine dipstick test performed and 94% a urine culture. The main pathogen was Escherichia coli. Reported indications were uncomplicated cystitis (32%), unspecified UTI (26%), complicated cystitis (9%), while no reason was given in 25% of cases. Only 10% of diagnoses were consistent with the guidelines: complicated cystitis (49%), asymptomatic bacteriuria (21%), acute pyelonephritis (21%), male UTI (9%). Almost 85% of prescriptions were active on the isolated bacteria. The empirical antibiotic therapy was consistent with the diagnosis in 16% of cases (30% for reclassified diagnoses). The two most prescribed antibiotic classes were fluoroquinolones (22.1%) and oral third-generation cephalosporins (19.1%). Only two of 157 possible de-escalations were performed. Duration of treatment was adequate for 19% of UTIs (9.6% of reclassified cases).
Our study revealed multiple deficiencies in diagnosis, antibiotic choice, treatment duration, and reevaluation.
Évaluation prospective de la prise en charge des infections urinaires (IU) dans les établissements d’hébergement pour personnes âgées dépendantes des Hauts-de-France.
Questionnaire (50 questions) pour cinq cas consécutifs d’IU maximum par établissement. Les diagnostics rapportés ont, si besoin, été corrigés selon les recommandations de la SPILF. Les résultats sont exprimés par rapport aux diagnostics supposés (rapportés) ou reclassifiés.
Sur 397 structures sollicitées, 134 ont participé et saisi 444 épisodes d’IU. Les symptômes étaient brûlures mictionnelles (32 %), urines malodorantes (29 %), confusion (28 %), urines troubles (19 %) ; 21 % des diagnostics d’IU reposaient sur des critères erronés. Moins de 50 % des résidents ont eu une bandelette urinaire et 94 % un ECBU. Le principal pathogène était Escherichia coli. Les motifs de prescription étaient cystite simple (32 %), IU sans précision (26 %), cystite compliquée (9 %), sans motif noté (25 %). Seuls 10 % des diagnostics étaient conformes aux recommandations : cystite compliquée (49 %), bactériurie asymptomatique (21 %), pyélonéphrite aiguë (21 %), IU masculine (9 %). La 1re ligne était adaptée au diagnostic dans 16 % des cas (30 % pour les diagnostics reclassés). Les antibiotiques les plus prescrits étaient fluoroquinolones (22,1 %) et C3G orales (19,1 %). Sur 157 désescalades possibles, deux ont été faites. La durée était conforme pour 19 % des IU (9,6 % des cas reclassés).
L’étude montre plusieurs lacunes sur les critères diagnostiques, le choix, la durée et la réévaluation des antibiotiques.
This work was presented in part at the 21st Interscience Congress on Chemotherapy, Washington 1984; the 14th International Congress of Chemotherapy, Kyoto 1985; and the annual meeting of the Royal College of Physicians and Surgeons of Canada, Vancouver 1985. This study was funded in part by a grant from the Foothills Hospital Research and Development Fund and in part by an Establishment Grant from the Alberta Heritage Foundation for Medical Research.
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Current address and address for reprint requests: Infection Control Unit, MS-675D, Health Sciences Centre, 820 Sherbrooke Street, Winnipeg, Manitoba, R3A 1R9 Canada.