1
|
Hall L, Hsu C, Slocum C, Lowry J. A physiatrist's role in managing unique challenges in pregnancy and delivery in a patient with incomplete lumbar SCI: a case report. Spinal Cord Ser Cases 2024; 10:40. [PMID: 38834538 PMCID: PMC11150403 DOI: 10.1038/s41394-024-00652-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Revised: 04/19/2024] [Accepted: 05/17/2024] [Indexed: 06/06/2024] Open
Abstract
INTRODUCTION Women of childbearing age make up around 5-10% of individuals with spinal cord injury (SCI) and may face unique medical and functional complications during pregnancy, including prolonged hospitalization and increased risk of early rehospitalization due to falls. CASE PRESENTATION Here, we discuss a case of a young ambulatory woman with a lumbar motor incomplete spinal cord injury who underwent successful delivery via cesarean section and the role of the physiatrist in the management of the patient's antepartum, intrapartum, and postpartum complications. The patient faced significant antepartum challenges secondary to her neurogenic bladder and pelvic floor weakness, resulting in increased use of her manual wheelchair. The physiatry team assisted with the co-development of a multidisciplinary bladder plan for increased urinary frequency and urinary tract infection prevention with the patient's obstetrics physician (OB). In addition, the physiatry team assisted with the procurement of a new wheelchair suited for the patient's pregnancy and childcare needs in anticipation of decreased mobility during this time. Regarding intrapartum challenges, the physiatry team worked with the patient and her OB to develop a safe birth plan considering the method of delivery, epidural usage, and the need for pelvic floor therapy before and after childbirth. DISCUSSION The patient had a successful cesarean section delivery, with return to independent mobility soon after childbirth. In summary, this case demonstrates that there is a need for a multidisciplinary approach to patients with SCI during pregnancy and that the role of physiatry is critical to optimizing medical and functional outcomes.
Collapse
Affiliation(s)
- Lauren Hall
- Spaulding Rehabilitation Hospital, Boston, MA, USA.
- Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, MA, USA.
| | - Connie Hsu
- Spaulding Rehabilitation Hospital, Boston, MA, USA
- Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, MA, USA
| | - Chloe Slocum
- Spaulding Rehabilitation Hospital, Boston, MA, USA
- Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, MA, USA
| | - John Lowry
- Spaulding Rehabilitation Hospital, Boston, MA, USA
- Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, MA, USA
| |
Collapse
|
2
|
Simoni A, Schwartz L, Junquera GY, Ching CB, Spencer JD. Current and emerging strategies to curb antibiotic-resistant urinary tract infections. Nat Rev Urol 2024:10.1038/s41585-024-00877-9. [PMID: 38714857 DOI: 10.1038/s41585-024-00877-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/26/2024] [Indexed: 05/23/2024]
Abstract
Rising rates of antibiotic resistance in uropathogenic bacteria compromise patient outcomes and prolong hospital stays. Consequently, new strategies are needed to prevent and control the spread of antibiotic resistance in uropathogenic bacteria. Over the past two decades, sizeable clinical efforts and research advances have changed urinary tract infection (UTI) treatment and prevention strategies to conserve antibiotic use. The emergence of antimicrobial stewardship, policies from national societies, and the development of new antimicrobials have shaped modern UTI practices. Future UTI management practices could be driven by the evolution of antimicrobial stewardship, improved and readily available diagnostics, and an improved understanding of how the microbiome affects UTI. Forthcoming UTI treatment and prevention strategies could employ novel bactericidal compounds, combinations of new and classic antimicrobials that enhance bacterial killing, medications that prevent bacterial attachment to uroepithelial cells, repurposing drugs, and vaccines to curtail the rising rates of antibiotic resistance in uropathogenic bacteria and improve outcomes in people with UTI.
Collapse
Affiliation(s)
- Aaron Simoni
- The Kidney and Urinary Tract Center, Nationwide Children's Abigail Wexner Research Institute, Columbus, OH, USA
| | - Laura Schwartz
- The Kidney and Urinary Tract Center, Nationwide Children's Abigail Wexner Research Institute, Columbus, OH, USA
- Department of Pediatrics, Division of Nephrology and Hypertension, Nationwide Children's, Columbus, OH, USA
- The Ohio State University College of Medicine, Columbus, OH, USA
| | - Guillermo Yepes Junquera
- Department of Pediatrics, Division of Infectious Diseases, Nationwide Children's, Columbus, OH, USA
| | - Christina B Ching
- The Kidney and Urinary Tract Center, Nationwide Children's Abigail Wexner Research Institute, Columbus, OH, USA
- Department of Urology, Nationwide Children's, Columbus, OH, USA
| | - John David Spencer
- The Kidney and Urinary Tract Center, Nationwide Children's Abigail Wexner Research Institute, Columbus, OH, USA.
- Department of Pediatrics, Division of Nephrology and Hypertension, Nationwide Children's, Columbus, OH, USA.
- The Ohio State University College of Medicine, Columbus, OH, USA.
| |
Collapse
|
3
|
Ramachandran A, Clottey KD, Gordon A, Hyett JA. Prediction and prevention of preterm birth: Quality assessment and systematic review of clinical practice guidelines using the AGREE II framework. Int J Gynaecol Obstet 2024. [PMID: 38619379 DOI: 10.1002/ijgo.15514] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Revised: 03/02/2024] [Accepted: 03/18/2024] [Indexed: 04/16/2024]
Abstract
BACKGROUND Prediction of pregnancies at risk of preterm birth (PTB) may allow targeted prevention strategies. OBJECTIVES To assess quality of clinical practice guidelines (CPGs) and identify areas of agreement and contention in prediction and prevention of spontaneous PTB. SEARCH STRATEGY We searched for CPGs regarding PTB prediction and prevention in asymptomatic singleton pregnancies without language restriction in January 2024. SELECTION CRITERIA CPGs included were published between July 2017 and December 2023 and contained statements intended to direct clinical practice. DATA COLLECTION AND ANALYSIS CPG quality was assessed using the AGREE-II tool. Recommendations were extracted and grouped under domains of prediction and prevention, in general populations and high-risk groups. MAIN RESULTS We included 37 CPGs from 20 organizations; all were of moderate or high quality overall. There was consensus in prediction of PTB by identification of risk factors and cervical length screening in high-risk pregnancies and prevention of PTB by universal screening and treatment for asymptomatic bacteriuria, screening and treatment for BV in high-risk pregnancies, and use of preventative progesterone and cerclage. Areas of contention or limited consensus were the role of PTB clinics, universal cervical length measurement, biomarkers and cervical pessaries. CONCLUSIONS This review identified strengths and limitations of current PTB CPGs, and areas for future research.
Collapse
Affiliation(s)
- Aparna Ramachandran
- Faculty of Medicine and Health, University of Sydney, Sydney, Australia
- Sydney Institute for Women, Children and Their Families, Sydney, Australia
| | - Klorkor D Clottey
- Department of Women and Babies, Royal Prince Alfred Hospital, Sydney, Australia
| | - Adrienne Gordon
- Faculty of Medicine and Health, University of Sydney, Sydney, Australia
- Sydney Institute for Women, Children and Their Families, Sydney, Australia
- Department of Neonatology, Royal Prince Alfred Hospital, Sydney, Australia
| | - Jon A Hyett
- Sydney Institute for Women, Children and Their Families, Sydney, Australia
- Department of Obstetrics and Gynecology, School of Medicine, Western Sydney University, Sydney, Australia
| |
Collapse
|
4
|
Bradley MS, Meckes N, Krishnamurti T. Decision-making and Treatment Preferences Surrounding Bacteriuria in Nonpregnant Women: A Qualitative Investigation. Int Urogynecol J 2024; 35:661-666. [PMID: 38324184 DOI: 10.1007/s00192-024-05725-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Accepted: 12/24/2023] [Indexed: 02/08/2024]
Abstract
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.
Collapse
Affiliation(s)
- Megan S Bradley
- Department of Obstetrics, Gynecology and Reproductive Science, Division of Urogynecology, University of Pittsburgh Medical Center - Magee Womens Hospital, 300 Halket St, Rm 2324, Pittsburgh, PA, 15213, USA.
| | - Nicole Meckes
- Department of Obstetrics, Gynecology and Reproductive Science, Division of Urogynecology, University of Pittsburgh Medical Center - Magee Womens Hospital, 300 Halket St, Rm 2324, Pittsburgh, PA, 15213, USA
| | - Tamar Krishnamurti
- Department of Internal Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| |
Collapse
|
5
|
Piazzolla HRW, Modin F, Halkjær SI, Petersen AM, Calum H, Holm A. The association between bacteriuria and adverse pregnancy outcomes: a systematic review and meta-analysis of observational studies. J Antimicrob Chemother 2024; 79:241-254. [PMID: 38073146 DOI: 10.1093/jac/dkad374] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Accepted: 11/24/2023] [Indexed: 02/02/2024] Open
Abstract
BACKGROUND Antibiotics for bacteriuria and urinary tract infection are commonly prescribed during pregnancy to avoid adverse pregnancy outcomes. The aim of this study was to evaluate the association between significant bacteriuria in pregnancy and any of the four pregnancy outcomes: preterm delivery; low birth weight; small for gestational age; and preterm labour. METHODS Systematic review with meta-analysis of observational studies. We searched PubMed, EMBASE, the Cochrane CENTRAL library, and Web of Science for observational studies published before 1 March 2022. The risk of bias was assessed using the Newcastle-Ottawa scale. Study identification, data extraction and risk-of-bias assessment was performed by two independent authors. We combined the included studies in meta-analyses and expressed results as ORs with 95% CIs (Prospero CRD42016053485). RESULTS We identified 58 studies involving 421 657 women. The quality of the studies was mainly poor or fair. The pooled, unadjusted OR for the association between any significant bacteriuria and: (i) preterm delivery was 1.62 (95% CI: 1.30-2.01; 27 studies; I2 = 61%); (ii) low birth weight was 1.50 (95% CI: 1.30-1.72; 47 studies; I2 = 74%); (iii) preterm labour was 2.29 (95% CI: 1.53-3.43; 3 studies; I2 = 0%); and (iv) small for gestational age was 1.33 (95% CI: 0.88-2.02; 7 studies; I2 = 54%). Four studies provided an adjusted OR, but were too diverse to combine in meta-analysis. CONCLUSIONS This systematic review identified an association between significant bacteriuria in pregnancy and the three complications: preterm delivery; low birth weight; and preterm labour. However, the quality of the available evidence is insufficient to conclude whether this association is merely due to confounding factors. There is a lack of high-quality evidence to support active identification and treatment of bacteriuria in pregnancy.
Collapse
Affiliation(s)
- Hans R W Piazzolla
- The Research Unit for General Practice and Section of General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Frederikke Modin
- The Research Unit for General Practice and Section of General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Sofie I Halkjær
- Gastrounit, Medical Section, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark
| | - Andreas M Petersen
- Gastrounit, Medical Section, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark
- Department of Clinical Microbiology, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark
| | - Henrik Calum
- Department of Clinical Microbiology, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark
| | - Anne Holm
- The Research Unit for General Practice and Section of General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| |
Collapse
|
6
|
Eiland LS, Harris JB, Holmes AP. Considerations for Treating Nonobstetric Diseases in Pregnant Patients in the Emergency Department Setting. Ann Pharmacother 2023; 57:1415-1424. [PMID: 37076990 DOI: 10.1177/10600280231167775] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/21/2023] Open
Abstract
OBJECTIVE To provide nonobstetric practitioners with an overview of key concepts for the pregnant patient and review treatment of 3 common acute nonobstetric diseases encountered in the emergency department setting. DATA SOURCES A literature search of PubMed was performed (1997-February 2023) using key search terms related to pregnancy, pain, urinary tract infection (UTI), venous thromboembolism (VTE), and anticoagulants. STUDY SELECTION AND DATA EXTRACTION Relevant articles in English and humans were considered. DATA SYNTHESIS When caring for a pregnant patient, it is important to utilize appropriate assessments, understand terms used in this population, and recognize how the physiological and pharmacokinetic changes that occur in pregnancy can influence medication use. Pain, UTIs, and VTE are common in this population. Acetaminophen is the most widely used medication for the management of pain during pregnancy and the drug of choice for mild pain in pregnancy not responsive to nonpharmacologic treatment. Pyelonephritis is the most common nonobstetric cause of hospitalization for pregnant patients. Antimicrobial treatment should consider maternal-fetal safety and local resistance patterns. Pregnant and postpartum patients have a 4- to 5-fold increased risk of developing a VTE compared with nonpregnant patients. Low-molecular-weight heparin is the preferred treatment. RELEVANCE TO PATIENT CARE AND CLINICAL PRACTICE Pregnant patients often seek acute care in the emergency department setting for nonobstetric needs. Pharmacists in this setting should understand appropriate assessment questions and terms used within this population, the basics of physiological and pharmacokinetic changes in pregnancy that can impact treatment, and which resources are best to utilize for drug information of the pregnant patient. CONCLUSION Practitioners in the acute care setting commonly encounter pregnant patients seeking care for nonobstetric concerns. This article covers key pregnancy-related information for the nonobstetric practitioner and focuses on the management of acute pain, UTI, and VTE during pregnancy.
Collapse
Affiliation(s)
- Lea S Eiland
- Department of Pharmacy Practice, Auburn University Harrison College of Pharmacy, Auburn, AL, USA
| | - John Brock Harris
- Education and Pharmaceutical Sciences Department, Wingate University School of Pharmacy, Wingate, NC, USA
| | - Amy P Holmes
- Department of Pharmacy, Atrium Wake Forest Baptist Health, Winston-Salem, NC, USA
| |
Collapse
|
7
|
Khapre M, Sharma D, Mehta A, Sinha S. Prevalence of Asymptomatic Bacteriuria (ASB) in Pregnant Women in India: A Systematic Review and Meta-Analysis. Indian J Community Med 2023; 48:879-887. [PMID: 38249695 PMCID: PMC10795867 DOI: 10.4103/ijcm.ijcm_795_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Accepted: 10/01/2023] [Indexed: 01/23/2024] Open
Abstract
Background Asymptomatic bacteriuria is prevalent during pregnancy. If it goes undetected, it can lead to urinary tract infection with severe maternal and neonatal complications. Until date, India does not have any guidelines to test for ASB during pregnancy. Objective To estimate the pooled prevalence of asymptomatic bacteriuria in pregnant women at national level in India. Material and Methods We searched Medline, Embase, Web of Science, and Google Scholar using search strategy with keyword. Two authors independently assessed the eligibility of study. The checklist of the JBI was used for evaluating the quality of reporting. The extracted data were analyzed, and the results were reported using a random-effects model with 95% confidence interval (CI). Subgroup analysis was conducted for zones of India, parity and trimester. Publication bias is reported as funnel plot. Result Pooled prevalence of asymptomatic bacteriuria among pregnant women in India is 13.5% [CI 11.1; 15.8]. Subgroup analysis based on the various geographic zones of the country the pooled prevalence ranged from 9.2% in central zone to 14.8% in south zone. Distribution of prevalence of ASB as per parity was approximately identical. The prevalence of ASB was found to be high in third (21.8%). Conclusion The prevalence of ASB is found to be high among Indian pregnant women, especially in third trimester. It is therefore recommended for guideline to screen and treat every pregnant woman for ASB to prevent further complications.
Collapse
Affiliation(s)
- Meenakshi Khapre
- Department of Community and Family Medicine, AIIMS, Rishikesh, Uttarakhand, India
| | - Divita Sharma
- Department of Community and Family Medicine, AIIMS, Rishikesh, Uttarakhand, India
| | - Aprajita Mehta
- Department of Community and Family Medicine, AIIMS, Rishikesh, Uttarakhand, India
| | - Smita Sinha
- Department of Community and Family Medicine, AIIMS, Rishikesh, Uttarakhand, India
| |
Collapse
|
8
|
Abstract
SUMMARY Urinary tract infection (UTI) is one of the more common perinatal complications, affecting approximately 8% of pregnancies (1, 2). These infections represent a spectrum, from asymptomatic bacteriuria, to symptomatic acute cystitis, to the most serious, pyelonephritis. The presence of UTIs has been associated with adverse pregnancy outcomes, including increased rates of preterm delivery and low birth weight. Screening for and treating asymptomatic bacteriuria have been shown in multiple studies to reduce the incidence of pyelonephritis in pregnancy (3-5). Given the frequency at which UTIs are encountered in pregnancy, the ability to recognize, diagnose, and treat them is essential for those providing care to pregnant individuals. This Clinical Consensus document was developed using an established protocol in conjunction with the authors listed.
Collapse
|
9
|
Seheult JN, Stram MN, Contis L, Pontzer RE, Hardy S, Wertz W, Baxter CM, Ondras M, Kip PL, Snyder GM, Pasculle AW. Development, Evaluation, and Multisite Deployment of a Machine Learning Decision Tree Algorithm To Optimize Urinalysis Parameters for Predicting Urine Culture Positivity. J Clin Microbiol 2023; 61:e0029123. [PMID: 37227272 PMCID: PMC10281150 DOI: 10.1128/jcm.00291-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Accepted: 04/21/2023] [Indexed: 05/26/2023] Open
Abstract
PittUDT, a recursive partitioning decision tree algorithm for predicting urine culture (UC) positivity based on macroscopic and microscopic urinalysis (UA) parameters, was developed in support of a broader system-wide diagnostic stewardship initiative to increase appropriateness of UC testing. Reflex algorithm training utilized results from 19,511 paired UA and UC cases (26.8% UC positive); the average patient age was 57.4 years, and 70% of samples were from female patients. Receiver operating characteristic (ROC) analysis identified urine white blood cells (WBCs), leukocyte esterase, and bacteria as the best predictors of UC positivity, with areas under the ROC curve of 0.79, 0.78, and 0.77, respectively. Using the held-out test data set (9,773 cases; 26.3% UC positive), the PittUDT algorithm met the prespecified target of a negative predictive value above 90% and resulted in a 30 to 60% total negative proportion (true-negative plus false-negative predictions). These data show that a supervised rule-based machine learning algorithm trained on paired UA and UC data has adequate predictive ability for triaging urine specimens by identifying low-risk urine specimens, which are unlikely to grow pathogenic organisms, with a false-negative proportion under 5%. The decision tree approach also generates human-readable rules that can be easily implemented across multiple hospital sites and settings. Our work demonstrates how a data-driven approach can be used to optimize UA parameters for predicting UC positivity in a reflex protocol, with the intent of improving antimicrobial stewardship and UC utilization, a potential avenue for cost savings.
Collapse
Affiliation(s)
- Jansen N. Seheult
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Michelle N. Stram
- Department of Forensic Medicine, NYU Langone Health, New York, New York, USA
| | - Lydia Contis
- Department of Pathology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Raymond E. Pontzer
- Infection Control and Hospital Epidemiology, UPMC, Pittsburgh, Pennsylvania, USA
| | - Stephanie Hardy
- Laboratory Service Center, UPMC, Pittsburgh, Pennsylvania, USA
| | - William Wertz
- Laboratory Service Center, UPMC, Pittsburgh, Pennsylvania, USA
| | | | - Michael Ondras
- Laboratory Service Center, UPMC, Pittsburgh, Pennsylvania, USA
| | - Paula L. Kip
- Wolff Center, UPMC, Pittsburgh, Pennsylvania, USA
| | - Graham M. Snyder
- Infection Control and Hospital Epidemiology, UPMC, Pittsburgh, Pennsylvania, USA
- Division of Infectious Diseases, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - A. William Pasculle
- Department of Pathology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Clinical Microbiology Laboratory, UPMC, Pittsburgh, Pennsylvania, USA
| |
Collapse
|
10
|
Winkler ML, Huang J, Starr J, Hooper DC, Paras ML, Letourneau AR, Shenoy ES. If you don't test, they will not treat: Impact of stopping preoperative screening for asymptomatic bacteriuria. ANTIMICROBIAL STEWARDSHIP & HEALTHCARE EPIDEMIOLOGY : ASHE 2023; 3:e95. [PMID: 37256152 PMCID: PMC10226188 DOI: 10.1017/ash.2023.166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Revised: 03/29/2023] [Accepted: 03/31/2023] [Indexed: 06/01/2023]
Abstract
Objective Screening for asymptomatic bacteriuria (ASB) is not recommended outside of patients undergoing invasive urological procedures and during pregnancy. Despite national guidelines recommending against screening for ASB, this practice is prevalent. We present outcomes from a quality-improvement intervention targeting patients undergoing cardiac artery bypass grafting surgery (CABG) at Massachusetts General Hospital, a tertiary-care hospital in Boston, Massachusetts, where preoperative testing checklists were modified to remove routine urinalysis and urine culture. This was a before-and-after intervention study. Methods Prior to the intervention, screening for ASB was included in the preoperative check list for all patients undergoing CABG. We assessed the proportion of patients undergoing screening for ASB in the 6 months prior to and after the intervention. We estimated cost savings from averted laboratory analyses, and we evaluated changes in antibiotic prescriptions. We additionally examined the incidence of postoperative surgical-site infections (SSIs), central-line-associated bloodstream infections (CLABSIs), catheter-associated urinary tract infections (CAUTIs) and Clostridioides difficile infections (CDIs). Results Comparing the pre- and postintervention periods, urinalyses decreased by 76.5% and urine cultures decreased by 87.0%, with an estimated cost savings of $8,090.38. There were 50% fewer antibiotic prescriptions for bacteriuria after the intervention. Conclusions Removal of urinalysis and urine culture from preoperative checklists for cardiac surgery led to a statistically significant decrease in testing without an increase in SSIs, CLABSIs, CAUTIs, or CDI. Challenges identified included persistence of checklists in templated order sets in the electronic health record.
Collapse
Affiliation(s)
- Marisa L. Winkler
- Division of Infectious Disease, Massachusetts General Hospital, Boston, Massachusetts
- Department of Medicine, Harvard Medical School, Boston, Massachusetts
- Department of Microbiology, Brigham and Women’s Hospital, Boston, Massachusetts
- Infection Control Unit, Massachusetts General Hospital, Boston, Massachusetts
| | - Joanne Huang
- Department of Pharmacy, Massachusetts General Hospital, Boston, Massachusetts
| | - Jessica Starr
- Department of Cardiac Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - David C. Hooper
- Division of Infectious Disease, Massachusetts General Hospital, Boston, Massachusetts
- Department of Medicine, Harvard Medical School, Boston, Massachusetts
- Infection Control Unit, Massachusetts General Hospital, Boston, Massachusetts
| | - Molly L. Paras
- Division of Infectious Disease, Massachusetts General Hospital, Boston, Massachusetts
- Department of Medicine, Harvard Medical School, Boston, Massachusetts
| | - Alyssa R. Letourneau
- Division of Infectious Disease, Massachusetts General Hospital, Boston, Massachusetts
- Department of Medicine, Harvard Medical School, Boston, Massachusetts
| | - Erica S. Shenoy
- Division of Infectious Disease, Massachusetts General Hospital, Boston, Massachusetts
- Department of Medicine, Harvard Medical School, Boston, Massachusetts
- Infection Control Unit, Massachusetts General Hospital, Boston, Massachusetts
| |
Collapse
|
11
|
Dickson K, Scott C, White H, Zhou J, Kelly M, Lehmann C. Antibacterial and Analgesic Properties of Beta-Caryophyllene in a Murine Urinary Tract Infection Model. Molecules 2023; 28:molecules28104144. [PMID: 37241885 DOI: 10.3390/molecules28104144] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Revised: 05/05/2023] [Accepted: 05/15/2023] [Indexed: 05/28/2023] Open
Abstract
Beta-caryophyllene has demonstrated anti-inflammatory effects in a variety of conditions, including interstitial cystitis. These effects are mediated primarily via the activation of the cannabinoid type 2 receptor. Additional antibacterial properties have recently been suggested, leading to our investigation of the effects of beta-caryophyllene in a murine model of urinary tract infection (UTI). Female BALB/c mice were intravesically inoculated with uropathogenic Escherichia coli CFT073. The mice received either beta-caryophyllene, antibiotic treatment using fosfomycin, or combination therapy. After 6, 24, or 72 h, the mice were evaluated for bacterial burden in the bladder and changes in pain and behavioral responses using von Frey esthesiometry. In the 24 h model, the anti-inflammatory effects of beta-caryophyllene were also assessed using intravital microscopy. The mice established a robust UTI by 24 h. Altered behavioral responses persisted 72 h post infection. Treatment with beta-caryophyllene resulted in a significant reduction in the bacterial burden in urine and bladder tissues 24 h post UTI induction and significant improvements in behavioral responses and intravital microscopy parameters, representing reduced inflammation in the bladder. This study demonstrates the utility of beta-caryophyllene as a new adjunct therapy for the management of UTI.
Collapse
Affiliation(s)
- Kayle Dickson
- Department of Microbiology and Immunology, Dalhousie University, Halifax, NS B3H 4R2, Canada
| | - Cassidy Scott
- Department of Pharmacology, Dalhousie University, Halifax, NS B3H 4R2, Canada
| | - Hannah White
- Department of Pharmacology, Dalhousie University, Halifax, NS B3H 4R2, Canada
| | - Juan Zhou
- Department of Anesthesiology, Pain Management and Perioperative Medicine, Dalhousie University, Halifax, NS B3H 4R2, Canada
| | - Melanie Kelly
- Department of Pharmacology, Dalhousie University, Halifax, NS B3H 4R2, Canada
| | - Christian Lehmann
- Department of Microbiology and Immunology, Dalhousie University, Halifax, NS B3H 4R2, Canada
- Department of Pharmacology, Dalhousie University, Halifax, NS B3H 4R2, Canada
- Department of Anesthesiology, Pain Management and Perioperative Medicine, Dalhousie University, Halifax, NS B3H 4R2, Canada
- Department of Physiology and Biophysics, Dalhousie University, Halifax, NS B3H 4R2, Canada
| |
Collapse
|
12
|
Comini J, Vines-Douglas G, Loeza M. Emerging Perinatal Infections. PHYSICIAN ASSISTANT CLINICS 2023. [DOI: 10.1016/j.cpha.2023.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/29/2023]
|
13
|
Dube R, Al-Zuheiri STS, Syed M, Harilal L, Zuhaira DAL, Kar SS. Prevalence, Clinico-Bacteriological Profile, and Antibiotic Resistance of Symptomatic Urinary Tract Infections in Pregnant Women. Antibiotics (Basel) 2022; 12:antibiotics12010033. [PMID: 36671233 PMCID: PMC9855124 DOI: 10.3390/antibiotics12010033] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Revised: 12/21/2022] [Accepted: 12/22/2022] [Indexed: 12/28/2022] Open
Abstract
Background: Urinary tract infection (UTI) is a common complication in pregnancy. The prevalence varies between countries. This research aims at estimating the prevalence, clinico-bacteriological profile, antibiotic resistance, and risk factor analysis of symptomatic UTI in pregnancy. Method: This is a prospective observational study conducted at the Abdullah Bin Omran Hospital, RAK, UAE, from March 2019 to February 2020. All pregnant women attending the antenatal clinic during this period were given a pre-validated questionnaire for the symptoms of UTI. In symptomatic patients, urine was sent for microscopy, culture, and sensitivity. Women were treated for UTI and were followed up for the rest of the pregnancy. Data analysis was performed by SPSS software version 24 using descriptive statistics and comparisons with significance at a p-value of <0.05. Results: The prevalence of symptomatic UTI was 17.9%. E.coli was the commonest isolate followed by Group B streptococcus. The commonest symptom reported was loin pain and the most common risk factor was diabetes. Women with risk factors are significantly more likely to have culture-positive UTIs. Most of the pathogens were sensitive to cefuroxime and benzyl penicillin. Risk of preterm labor was higher. Conclusions: Regular antenatal care and routine urine testing in all visits are recommended for early detection and treatment of UTI.
Collapse
Affiliation(s)
- Rajani Dube
- Department of Obstetrics and Gynecology, RAK Medical and Health Sciences University, Ras Al Khaimah 11172, United Arab Emirates
- Correspondence: ; Tel.: +971-551383304
| | - Shatha Taher Salman Al-Zuheiri
- Department of Obstetrics and Gynecology, Abdullah Bin Omran Hospital for Obstetrics and Gynecology, Ras Al Khaimah 11172, United Arab Emirates
| | - Mariyam Syed
- Department of Obstetrics and Gynecology, RAK Medical and Health Sciences University, Ras Al Khaimah 11172, United Arab Emirates
| | - Lekshmi Harilal
- Department of Obstetrics and Gynecology, RAK Medical and Health Sciences University, Ras Al Khaimah 11172, United Arab Emirates
| | - Dean Allah Layth Zuhaira
- Department of Obstetrics and Gynecology, RAK Medical and Health Sciences University, Ras Al Khaimah 11172, United Arab Emirates
| | - Subhranshu Sekhar Kar
- Department of Pediatrics and Neonatology, RAK Medical and Health Sciences University, Ras Al Khaimah 11172, United Arab Emirates
| |
Collapse
|
14
|
AlShamlan NA, AlOmar RS, Aldossary R, Alahmari M, Alghamdi A, AlGhamdi M, Alkanaan N, AlReedy AH, AlOtaibi AS, Alghamdi NS. The Epidemiology, Associated Factors and Bacterial Profile of Asymptomatic Bacteriuria in Pregnant Women: A Retrospective Chart Review Study in Saudi Arabia. Int J Womens Health 2022; 14:1749-1759. [PMID: 36561606 PMCID: PMC9766479 DOI: 10.2147/ijwh.s394936] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Accepted: 12/13/2022] [Indexed: 12/23/2022] Open
Abstract
Purpose Asymptomatic bacteriuria (ASB) is the presence of significant amounts of bacteria within the urinary tract in the absence of urinary tract infection (UTI) symptoms, resulting in negative neonatal and pregnancy consequences. This study determined the prevalence, bacteriology patterns, and associated factors with ASB among pregnant women in both primary and hospital levels of care in the Eastern Province of Saudi Arabia. Methods This retrospective chart review study included pregnant women between 18 and 50 years who performed the screening urine culture test during their first antenatal visit between 2017 and 2021, without UTI symptoms. The collected data involved the demographic, medical, and obstetric characteristics, and urine culture results. T-tests and chi-squared tests were used for bivariate associations followed by binary logistic regression models. Results ASB was positive among 03.42% of the 6471 pregnant women included in the study. Logistic regression revealed that the risk of positive ASB increased in pregnant women in the first and second trimesters (OR = 2.04, 95% CI = 1.41-2.93 and OR= 1.50, 95% CI = 1.03-2.19, respectively), as well as pregnant women with a history of previous UTI (OR = 2.98, 95% CI = 2.14-4.15). The predominant organism isolates were E. coli, followed by GBS, Klebsiella pneumoniae, and Enterococcus faecalis. Conclusion With limited data on ASB among pregnant women in Saudi Arabia, findings from the current study could help decision-makers in the country assess the epidemiological characteristics of the condition. Further study is recommended to investigate the susceptibility patterns of commonly prescribed antibiotics with different uropathogens to guide the clinicians who deal with these cases. Additionally, a large national study across the other regions in the kingdom is suggested to calculate the prevalence of ASB in Saudi Arabia.
Collapse
Affiliation(s)
- Nouf A AlShamlan
- Department of Family and Community Medicine, College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia,Correspondence: Nouf A AlShamlan, College of Medicine, Imam Abdulrahman Bin Faisal University, P.O. Box 1982, Dammam, 34224, Saudi Arabia, Tel +966504901406, Email
| | - Reem S AlOmar
- Department of Family and Community Medicine, College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Roba Aldossary
- College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Maha Alahmari
- College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Asma Alghamdi
- College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Mawaddah AlGhamdi
- College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Najla Alkanaan
- College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Abdullah H AlReedy
- Department of Family and Community Medicine, College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Amani S AlOtaibi
- Department of Obstetrics and Gynaecology, College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Nada S Alghamdi
- Department of Microbiology, College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| |
Collapse
|
15
|
Valentine-King M, Van J, Hines-Munson C, Dillon L, Graber CJ, Patel PK, Drekonja D, Lichtenberger P, Shukla B, Kramer J, Ramsey D, Trautner B, Grigoryan L. Identification of novel factors associated with inappropriate treatment of asymptomatic bacteriuria in acute and long-term care. Am J Infect Control 2022; 50:1226-1233. [PMID: 35158007 DOI: 10.1016/j.ajic.2022.02.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Revised: 02/03/2022] [Accepted: 02/05/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Chart reviews often fall short of determining what drove antibiotic treatment of asymptomatic bacteriuria (ASB). To overcome this shortcoming, we searched providers' free-text for documentation of their decision-making and for misleading signs and symptoms that may trigger unnecessary treatment of ASB. METHODS We reviewed a random sample of 10 positive urine cultures per month, per facility, from patients in acute or long-term care wards at 8 Veterans Affairs facilities. Cultures were classified as urinary tract infection (UTI) or ASB, and as treated or untreated. Charts were searched for 13 potentially misleading symptoms, and free-text documentation of providers' decision-making was classified into 5 categories. We used generalized estimating equations logistic regression to identify factors associated with ASB treatment. RESULTS One hundred fifty-eight (27.5%) of 575 ASB cases were inappropriately treated with antibiotics. Significant factors associated with inappropriate treatment included: abdominal pain, falls, decreased urine output, urine characteristics, abnormal vital signs, laboratory values, and voiding issues. Providers prescribed an average of 1.4 antimicrobials to patients with ASB, with cephalosporins (41%) and fluoroquinolones (21%) being the most common classes prescribed. CONCLUSIONS Chart reviews of providers' decision-making highlighted new factors associated with inappropriate ASB treatment. These findings can help design antibiotic stewardship interventions for ASB.
Collapse
Affiliation(s)
- Marissa Valentine-King
- Department of Family and Community Medicine, Baylor College of Medicine, Houston, TX; Center for Innovations in Quality, Effectiveness and Safety (IQuESt), Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX.
| | - John Van
- Center for Innovations in Quality, Effectiveness and Safety (IQuESt), Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX; Department of Medicine, Section of Health Services Research, Baylor College of Medicine, Houston, TX
| | - Casey Hines-Munson
- Center for Innovations in Quality, Effectiveness and Safety (IQuESt), Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX; Department of Medicine, Section of Health Services Research, Baylor College of Medicine, Houston, TX
| | - Laura Dillon
- Center for Innovations in Quality, Effectiveness and Safety (IQuESt), Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX; Department of Medicine, Section of Health Services Research, Baylor College of Medicine, Houston, TX
| | - Christopher J Graber
- Infectious Diseases Section, Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, CA; Division of Infectious Diseases, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA
| | - Payal K Patel
- Department of Internal Medicine, Division of Infectious Diseases, University of Michigan Medical School, Ann Arbor, MI; Infectious Diseases Section, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, MI
| | - Dimitri Drekonja
- Department of Medicine, University of Minnesota, Minneapolis, MN; Minneapolis Veterans Affairs Health Care System, Minneapolis, MN
| | - Paola Lichtenberger
- Infectious Diseases Section, Veterans Affairs Miami Medical Center, Miami, FL; Department of Medicine, University of Miami Miller School of Medicine, Miami, FL
| | - Bhavarth Shukla
- Infectious Diseases Section, Veterans Affairs Miami Medical Center, Miami, FL; Department of Medicine, University of Miami Miller School of Medicine, Miami, FL
| | - Jennifer Kramer
- Center for Innovations in Quality, Effectiveness and Safety (IQuESt), Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX; Department of Medicine, Section of Health Services Research, Baylor College of Medicine, Houston, TX
| | - David Ramsey
- Center for Innovations in Quality, Effectiveness and Safety (IQuESt), Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX; Department of Medicine, Section of Health Services Research, Baylor College of Medicine, Houston, TX
| | - Barbara Trautner
- Center for Innovations in Quality, Effectiveness and Safety (IQuESt), Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX; Department of Medicine, Section of Health Services Research, Baylor College of Medicine, Houston, TX
| | - Larissa Grigoryan
- Department of Family and Community Medicine, Baylor College of Medicine, Houston, TX; Center for Innovations in Quality, Effectiveness and Safety (IQuESt), Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX
| |
Collapse
|
16
|
Childers R, Liotta B, Brennan J, Wang P, Kattoula J, Tran T, Montilla-Guedez H, Castillo EM, Vilke G. Urine testing is associated with inappropriate antibiotic use and increased length of stay in emergency department patients. Heliyon 2022; 8:e11049. [PMID: 36281377 PMCID: PMC9587269 DOI: 10.1016/j.heliyon.2022.e11049] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Revised: 09/05/2022] [Accepted: 10/07/2022] [Indexed: 11/06/2022] Open
Abstract
Background Exposing patients with a low probability of disease to diagnostic testing with poor test characteristics leads to false positive results. Providers often act on these false results, which can cause unnecessary evaluation and treatment. The treatment of asymptomatic bacteriuria is discouraged, but it still frequently occurs in the inpatient setting; it is less studied in the Emergency Department (ED). In this study, we examine associations between urine testing, inappropriate antibiotic use, and length of stay in discharged ED patients at risk of urinary tract infection (UTI) misdiagnosis. Methods A cohort of discharged ED patients at risk of UTI misdiagnosis was created by pulling visit information for patients presenting with abdominal pain, chest pain, headache, vaginal bleeding in pregnancy, and elderly females with weakness or confusion. Predictors of urine testing, and urinary tract infection treatment were determined with logistic regression analysis. A chart review of a representative sample of this cohort was then completed screening for the presence of urinary tract symptoms and urine culture results. Linear regression analysis was then used to generate an adjusted mean difference in length of stay between patients who had urine testing compared to those who did not. Results About a quarter of chest pain and headache patients had urine testing, while approximately 75% of abdominal pain patients, vaginal bleeding in pregnancy, and elderly females with weakness or confusion did. Except for chest pain patients, the UTI treatment rate was more than double the positive culture rate, indicating overtreatment. A diagnosis of UTI is based on a combination of UTI symptoms and positive urine cultures, yet only about 15% of patients treated for UTI met these criteria. Lastly, in all chief complaint groups, the length of stay was significantly longer-30 min or more-for those who had urine testing compared to matched controls. Conclusions In this observational study of patients at risk of UTI misdiagnosis, urine testing was associated with inappropriate antibiotic use and delayed discharge. There is pressure on providers to perform diagnostic testing, but in patients without specific UTI symptoms, urine testing might cause more harm than benefit.
Collapse
|
17
|
Welch JM, Zhuang T, Shapiro LM, Harris AHS, Baker LC, Kamal RN. Is Low-value Testing Before Low-risk Hand Surgery Associated With Increased Downstream Healthcare Use and Reimbursements? A National Claims Database Analysis. Clin Orthop Relat Res 2022; 480:1851-1862. [PMID: 35608508 PMCID: PMC9473771 DOI: 10.1097/corr.0000000000002255] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Accepted: 05/05/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND Minor hand procedures can often be completed in the office without any laboratory testing. Preoperative screening tests before minor hand procedures are unnecessary and considered low value because they can lead to preventable invasive confirmatory tests and/or procedures. Prior studies have shown that low-value testing before low-risk hand surgery is still common, yet little is known about their downstream effects and associated costs. Assessing these downstream events can elucidate the consequences of obtaining a low-value test and inform context-specific interventions to reduce their use. QUESTIONS/PURPOSES (1) Among healthy adults undergoing low-risk hand surgery, are patients who receive a preoperative low-value test more likely to have subsequent diagnostic tests and procedures than those who do not receive a low-value test? (2) What is the increased 90-day reimbursement associated with subsequent diagnostic tests and procedures in patients who received a low-value test compared with those who did not? METHODS In this retrospective, comparative study using a large national database, we queried a large health insurance provider's administrative claims data to identify adult patients undergoing low-risk hand surgery (carpal tunnel release, trigger finger release, Dupuytren fasciectomy, de Quervain release, thumb carpometacarpal arthroplasty, wrist ganglion cyst, or mass excision) between 2011 and 2017. This database was selected for its ability to track patient claims longitudinally with direct provision of reimbursement data in a large, geographically diverse patient population. Patients who received at least one preoperative low-value test, including complete blood count, basic metabolic panel, electrocardiogram, chest radiography, pulmonary function test, and urinalysis within the 30-day preoperative period, were matched with propensity scores to those who did not. Among the 73,112 patients who met our inclusion criteria (mean age 57 ± 14 years; 68% [49,847] were women), 27% (19,453) received at least one preoperative low-value test and were propensity score-matched to those who did not. Multivariable regression analyses were performed to assess the frequency and reimbursements of subsequent diagnostic tests and procedures in the 90 days after surgery while controlling for potentially confounding variables such as age, sex, comorbidities, and baseline healthcare use. RESULTS When controlling for covariates such as age, sex, comorbidities, and baseline healthcare use, patients in the low-value test cohort had an adjusted odds ratio of 1.57 (95% confidence interval [CI] 1.50 to 1.64; p < 0.001) for a postoperative use event (a downstream diagnostic test or procedure) compared with those who did not have a low-value test. The median (IQR) per-patient reimbursements associated with downstream utilization events in patients who received a low-value test was USD 231.97 (64.37 to 1138.84), and those who did not receive a low-value test had a median of USD 191.52 (57.1 to 899.42) (adjusted difference when controlling for covariates: USD 217.27 per patient [95% CI 59.51 to 375.03]; p = 0.007). After adjusting for inflation, total additional reimbursements for patients in the low-value test cohort increased annually. CONCLUSION Low-value tests generate downstream tests and procedures that are known to provide minimal benefit to healthy patients and may expose patients to potential harms associated with subsequent, unnecessary invasive tests and procedures in response to false positives. Nevertheless, low-value testing remains common and the rising trend in low-value test-associated spending demonstrates the need for multicomponent interventions that target change at both the payer and health system level. Such interventions should disincentivize the initial low-value test and the cascade that may follow. Future work to identify the barriers and facilitators to reduce low-value testing in hand surgery can inform the development and revision of deimplementation strategies. LEVEL OF EVIDENCE Level III, therapeutic study.
Collapse
Affiliation(s)
- Jessica M. Welch
- VOICES Health Policy Research Center, Department of Orthopaedic Surgery, Stanford University, Redwood City, CA, USA
| | - Thompson Zhuang
- VOICES Health Policy Research Center, Department of Orthopaedic Surgery, Stanford University, Redwood City, CA, USA
| | | | - Alex H. S. Harris
- VOICES Health Policy Research Center, Department of Orthopaedic Surgery, Stanford University, Redwood City, CA, USA
- Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
| | - Laurence C. Baker
- Department of Health Research Policy, Stanford University, Stanford, CA, USA
| | - Robin N. Kamal
- VOICES Health Policy Research Center, Department of Orthopaedic Surgery, Stanford University, Redwood City, CA, USA
| |
Collapse
|
18
|
Cooper TE, Teng C, Howell M, Teixeira-Pinto A, Jaure A, Wong G. D-mannose for preventing and treating urinary tract infections. Cochrane Database Syst Rev 2022; 8:CD013608. [PMID: 36041061 PMCID: PMC9427198 DOI: 10.1002/14651858.cd013608.pub2] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Urinary tract infections (UTIs) are very common, affecting more than 7 million people worldwide. Whilst many people may only experience a single episode in their lifetime and are generally responsive to standard antibiotics, a significant proportion of adults and children (approximately 15% to 25%) are chronic symptomatic UTI sufferers. Certain population groups are at greater risk than others, such as immunosuppressed and people with chronic kidney disease. D-mannose is a sugar part of normal human metabolism found within most diets. The mechanism of action is to prevent bacterial adherence to the uroepithelial cells. The D-mannose-based inhibitors can block uropathogenic Escherichia coli adhesion and invasion of the uroepithelial cells. The bacteria are then understood to essentially be eliminated by urination. Early pilot studies on animals and humans have trialled concentrated forms of D-mannose (tablets or sachets) in doses ranging from 200 mg up to 2 to 3 g and found possible efficacy in reducing UTI symptoms or recurrence. Although the anti-adhesive effects of D-mannose have been well-established, only recently have we seen a small number of pilot studies and small clinical trials conducted. OBJECTIVES To assess the benefits and harms of D-mannose for preventing and treating UTIs in adults and children. SEARCH METHODS We searched the Cochrane Kidney and Transplant Register of Studies up to 22 February 2022 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov. SELECTION CRITERIA We included RCTs measuring and reporting the effect of D-mannose, in any combination and any formulation, to prevent or treat UTIs in adults and children, females and males, in any setting (including perioperative). Authors independently assessed the retrieved titles and abstracts and, where necessary, the full text to determine which satisfied the inclusion criteria. DATA COLLECTION AND ANALYSIS Data extraction was independently carried out by two authors using a standard data extraction form. Methodological quality of the included studies was assessed using the Cochrane risk of bias tool. Data entry was carried out by one author and cross-checked by another author. The certainty of the evidence was assessed using the GRADE approach. MAIN RESULTS We included seven RCTs (719 participants) in adult females and males who had either acute cystitis or a history of recurrent (at least two episodes in six months or three episodes in 12 months) UTIs (symptomatic or asymptomatic). Two were prevention studies, four were prevention and treatment studies (two perioperative and one in people with multiple sclerosis), and one was a treatment study. Time periods ranged from 15 days to six months. No two studies were comparable (by dose or treatments), and we could not undertake meta-analyses. Individual studies reported no clear evidence to determine whether D-mannose is more or less effective in preventing or treating UTIs. D-mannose (2 g) had uncertain effects on symptomatic and bacteriuria-confirmed UTIs when compared to no treatment (1 study, 205 participants; very low certainty evidence) and antibiotics (nitrofurantoin 50 mg) (1 study, 206 participants; very low certainty evidence). D-mannose, in combination with herbal supplements, had uncertain effects on symptomatic and bacteria-confirmed UTI and pain when compared to no treatment (1 study, 40 participants; very low certainty evidence). D-mannose 500 mg plus supplements (N-acetylcysteine and Morinda citrifolia fruit extract) had uncertain effects on symptomatic and bacteriuria-confirmed UTIs when compared to an antibiotic (prulifloxacin 400 mg) (1 study, 75 participants; very low certainty evidence). Adverse events were very few and poorly reported; none were serious (mostly diarrhoea and vaginal burning). Overall, the quality of the evidence is poor. Most studies were judged to have unclear or high risk of bias across most domains. Data was sparse and addressed very few outcomes. The GRADE evaluation was rated as very low certainty evidence due to very serious limitations in the study design or execution (high risk of bias across all studies) and sparse data (single study data and small sample sizes). AUTHORS' CONCLUSIONS There is currently little to no evidence to support or refute the use of D-mannose to prevent or treat UTIs in all populations. This review highlights the severe lack of high-quality RCTs testing the efficacy of D-mannose for UTIs in any population. Despite UTIs being one of the most common adult infections (affecting 50% of women at least once in their lifetime) and the growing global antimicrobial resistance, we found very few studies that adequately test this alternative treatment. Future research in this field requires, in the first instance, a single adequately powered RCT comparing D-mannose with placebo.
Collapse
Affiliation(s)
- Tess E Cooper
- Cochrane Kidney and Transplant, Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, Australia
- Sydney School of Public Health, The University of Sydney, Sydney, Australia
| | - Claris Teng
- Sydney School of Public Health, The University of Sydney, Sydney, Australia
- Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, Australia
| | - Martin Howell
- Sydney School of Public Health, The University of Sydney, Sydney, Australia
- Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, Australia
| | - Armando Teixeira-Pinto
- Sydney School of Public Health, The University of Sydney, Sydney, Australia
- Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, Australia
| | - Allison Jaure
- Sydney School of Public Health, The University of Sydney, Sydney, Australia
- Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, Australia
| | - Germaine Wong
- Sydney School of Public Health, The University of Sydney, Sydney, Australia
- Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, Australia
- Centre for Transplant and Renal Research, Westmead Hospital, Westmead, Australia
| |
Collapse
|
19
|
Grigoryan L, Naik AD, Lichtenberger P, Graber CJ, Patel PK, Drekonja DM, Gauthier TP, Shukla B, Sales AE, Krein SL, Van JN, Dillon LM, Hysong SJ, Kramer JR, Walder A, Ramsey D, Trautner BW. Analysis of an Antibiotic Stewardship Program for Asymptomatic Bacteriuria in the Veterans Affairs Health Care System. JAMA Netw Open 2022; 5:e2222530. [PMID: 35877123 PMCID: PMC9315417 DOI: 10.1001/jamanetworkopen.2022.22530] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
IMPORTANCE Antibiotic stewardship for asymptomatic bacteriuria (ASB) is an important quality improvement target. Understanding how to implement successful antibiotic stewardship interventions is limited. OBJECTIVE To evaluate the effectiveness of a quality improvement stewardship intervention on reducing unnecessary urine cultures and antibiotic use in patients with ASB. DESIGN, SETTING, AND PARTICIPANTS This interrupted time series quality improvement study was performed at the acute inpatient medical and long-term care units of 4 intervention sites and 4 comparison sites in the Veterans Affairs (VA) health care system from October 1, 2017, through April 30, 2020. Participants included the clinicians who order or collect urine cultures and who order, dispense, or administer antibiotics. Clinical outcomes were measured in all patients in a study unit during the study period. Data were analyzed from July 6, 2020, to May 24, 2021. INTERVENTION Case-based teaching on how to apply an evidence-based algorithm to distinguish urinary tract infection and ASB. The intervention was implemented through external facilitation by a centralized coordinating center, with a site champion at each intervention site serving as an internal facilitator. MAIN OUTCOMES AND MEASURES Urine culture orders and days of antibiotic therapy (DOT) and length of antibiotic therapy in days (LOT) associated with urine cultures, standardized by 1000 bed-days, were obtained from the VA's Corporate Data Warehouse. RESULTS Of 11 299 patients included, 10 703 (94.7%) were men, with a mean (SD) age of 72.6 (11.8) years. The decrease in urine cultures before and after the intervention was not significant in intervention sites per segmented regression analysis (-0.04 [95% CI, -0.17 to 0.09]; P = .56). However, difference-in-differences analysis comparing intervention with comparison sites found a significant reduction in the number of urine cultures ordered by 3.24 urine cultures per 1000 bed-days (P = .003). In the segmented regression analyses, the relative percentage decrease of DOT in the postintervention period at the intervention sites was 21.7% (P = .007), from 46.1 (95% CI, 28.8-63.4) to 37.0 (95% CI, 22.6-51.4) per 1000 bed-days. The relative percentage decrease of LOT in the postintervention period at the intervention sites was 21.0% (P = .001), from 36.7 (95% CI, 23.2-50.2) to 29.6 (95% CI, 18.2-41.0) per 1000 bed-days. CONCLUSIONS AND RELEVANCE The findings of this quality improvement study suggest that an individualized intervention for antibiotic stewardship for ASB was associated with a decrease in urine cultures and antibiotic use when implemented at multiple sites via external and internal facilitation. The electronic health record database-derived outcome measures and centralized facilitation approach are both suitable for dissemination.
Collapse
Affiliation(s)
- Larissa Grigoryan
- Department of Family and Community Medicine, Baylor College of Medicine, Houston, Texas
- Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey Veterans Affairs (VA) Medical Center, Houston, Texas
| | - Aanand D. Naik
- Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey Veterans Affairs (VA) Medical Center, Houston, Texas
- Department of Management, Policy and Community Health, School of Public Health, University of Texas Health Science Center, Houston
- Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Paola Lichtenberger
- Department of Medicine, University of Miami Miller School of Medicine and the Miami VA Healthcare System, University of Miami, Miami, Florida
| | - Christopher J. Graber
- Infectious Diseases Section, VA Greater Los Angeles Healthcare System and David Geffen School of Medicine at UCLA (University of California, Los Angeles)
| | - Payal K. Patel
- Division of Infectious Diseases, Department of Medicine, University of Michigan and VA Ann Arbor Healthcare System, Ann Arbor
| | - Dimitri M. Drekonja
- Division of Infectious Diseases and International Medicine, University of Minnesota Medical School and Minneapolis VA Health Care System, Minneapolis
| | | | - Bhavarth Shukla
- Department of Medicine, University of Miami Miller School of Medicine and the Miami VA Healthcare System, University of Miami, Miami, Florida
| | - Anne E. Sales
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan
- Department of Learning Health Sciences, University of Michigan Medical School, Ann Arbor
| | - Sarah L. Krein
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan
| | - John N. Van
- Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey Veterans Affairs (VA) Medical Center, Houston, Texas
| | - Laura M. Dillon
- Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey Veterans Affairs (VA) Medical Center, Houston, Texas
| | - Sylvia J. Hysong
- Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey Veterans Affairs (VA) Medical Center, Houston, Texas
- Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Jennifer R. Kramer
- Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey Veterans Affairs (VA) Medical Center, Houston, Texas
- Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Annette Walder
- Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey Veterans Affairs (VA) Medical Center, Houston, Texas
- Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - David Ramsey
- Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey Veterans Affairs (VA) Medical Center, Houston, Texas
- Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Barbara W. Trautner
- Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey Veterans Affairs (VA) Medical Center, Houston, Texas
- Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas
| |
Collapse
|
20
|
Rolfs J. Common Infections Encountered in Obstetrics/Gynecology. PHYSICIAN ASSISTANT CLINICS 2022. [DOI: 10.1016/j.cpha.2022.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
|
21
|
Antimicrobial Stewardship for the Infusion Nurse. JOURNAL OF INFUSION NURSING 2022; 45:201-209. [PMID: 35820124 DOI: 10.1097/nan.0000000000000472] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
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.
Collapse
|
22
|
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. DISEASE MARKERS 2022; 2022:7056517. [PMID: 35531475 PMCID: PMC9072028 DOI: 10.1155/2022/7056517] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Accepted: 04/02/2022] [Indexed: 11/17/2022]
Abstract
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
,
,
, and
). 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 (
). 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.
Collapse
|
23
|
Gourevitch RA, Natwick T, Chaisson CE, Weiseth A, Shah NT. Variation in guideline-based prenatal care in a commercially insured population. Am J Obstet Gynecol 2022; 226:413.e1-413.e19. [PMID: 34614398 DOI: 10.1016/j.ajog.2021.09.038] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Revised: 09/28/2021] [Accepted: 09/29/2021] [Indexed: 01/04/2023]
Abstract
BACKGROUND Despite the importance of prenatal care, quality measurement efforts have focused on the number of prenatal visits, or prenatal care adequacy, rather than the services received. It is unknown whether attending more prenatal visits is associated with receiving more guideline-based prenatal care services. The relationship between guideline-based prenatal care and patients' clinical and sociodemographic characteristics has also not been studied. OBJECTIVE This study aimed to measure the receipt of guideline-based prenatal care among pregnant patients and to describe the association between guideline-based prenatal care and the number of prenatal visits and other patient characteristics. STUDY DESIGN This was a retrospective descriptive cohort study of 176,092 pregnancy episodes between 2016 and 2019. We used de-identified administrative claims data on commercial enrollees across the United States from the OptumLabs Data Warehouse. We identified the following 8 components of prenatal care that are universally recommended by the American College of Obstetricians and Gynecologists and other guideline-issuing organizations: testing for sexually transmitted infections, obstetric laboratory test panel, urine culture, urinalysis, anatomy scan ultrasound, oral glucose tolerance test, tetanus, diphtheria, and pertussis vaccine, and group B Streptococcus test. We measured the proportion of pregnant patients who received each of these guideline-based services at the appropriate gestational age. We measured the association between guideline-based services and the number of prenatal visits and prenatal care adequacy. We described variation of guideline-based care according to patient age, comorbidities, high deductible health plan enrollment, and their county's rurality, health professional shortage area status, racial composition, median income, and educational attainment. RESULTS The 176,092 pregnancy episodes were mostly among patients aged 25 to 34 years (63%) with few pregnancy comorbidities (81%) and living in urban areas (92%). Guideline-based care varied by service, from 51% receiving a timely urinalysis to 90% receiving an anatomy scan and 91% completing testing for sexually transmitted infections. Patients with at least 4 prenatal visits received, on average, 6 of the 8 guideline-based services. Guideline-based care did not increase with additional prenatal visits and varied by patient characteristics. Rates of tetanus, diphtheria, and pertussis vaccination were lower in counties with high proportions of minoritized populations, lower education, and lower income. CONCLUSION In this commercially insured population, receipt of guideline-based care was not universal, did not increase with the number of prenatal visits, and varied by patient- and area-level characteristics. Measuring guideline-based care is feasible and may capture quality of prenatal care better than visit count or adequacy alone.
Collapse
Affiliation(s)
- Rebecca A Gourevitch
- Department of Health Care Policy, Harvard Medical School, Boston, MA; Delivery Decisions Initiative, Ariadne Labs, Boston, MA.
| | | | | | - Amber Weiseth
- Delivery Decisions Initiative, Ariadne Labs, Boston, MA
| | - Neel T Shah
- Delivery Decisions Initiative, Ariadne Labs, Boston, MA; Beth Israel Deaconess Medical Center, Boston, MA; OptumLabs Visiting Fellow, Cambridge, MA; Maven Clinic, New York, NY
| |
Collapse
|
24
|
De Seta F, Johnson Z, Stabile G, Martin A, Larsen B. Rational development and evaluation of novel formulations for urinary health. Eur J Obstet Gynecol Reprod Biol 2021; 269:90-97. [PMID: 34979364 DOI: 10.1016/j.ejogrb.2021.12.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Accepted: 12/23/2021] [Indexed: 11/04/2022]
Abstract
OBJECTIVE Urinary tract infections (UTI) among women form a substantial part of medical practice and both patients and medical professionals have an interest in non-antibiotic treatments and preventative measures. This research provides preliminary data on a multi-functional composition, DAPAD, which explored several biologic activities of relevance to UTI. STUDY DESIGN This formulation included D-mannose, citric acid, three prebiotic compounds, and extracts of dandelion and astragalus. Studies performed employed 4 bacterial strains that have relevance to UTI including E. coli, Proteus mirabilis, Streptococcus agalactiae and Enterococcus faecalis. RESULTS Key findings from in vitro studies included: DAPAD at full- and half-strength inhibited growth of all UTI bacteria. Evidence for D-mannose agglutination of E. coli was demonstrated. D-mannose also showed unexpected effects on bacterial membrane integrity with vital staining and modest growth restriction. We did not demonstrate growth inhibition by dandelion or astragalus extracts but the latter showed diminished cytokine elaboration by bladder epithelial cells. CONCLUSION DAPAD is a multifunctional composition that may warrant further development as a UTI treatment or preventive if supported by clinical evaluation.
Collapse
Affiliation(s)
- Francesco De Seta
- Department of Medical Sciences, University of Trieste, Institute for Maternal and Child Health- IRCCS, Burlo Garofolo, Trieste, Italy
| | - Zoe Johnson
- OB/GYN PGY1, Metro Health Hospital, Wyoming, MI, USA
| | - Guglielmo Stabile
- Institute for Maternal and Child Health-IRCCS, Burlo Garofolo, Trieste, Italy.
| | | | - Bryan Larsen
- Marian University College of Osteopathic Medicine (Retired), Indianapolis, IN, USA
| |
Collapse
|
25
|
Goebel MC, Trautner BW, Grigoryan L. The Five Ds of Outpatient Antibiotic Stewardship for Urinary Tract Infections. Clin Microbiol Rev 2021; 34:e0000320. [PMID: 34431702 PMCID: PMC8404614 DOI: 10.1128/cmr.00003-20] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Urinary tract infections (UTI) are one of the most common indications for antibiotic prescriptions in the outpatient setting. Given rising rates of antibiotic resistance among uropathogens, antibiotic stewardship is critically needed to improve outpatient antibiotic use, including in outpatient clinics (primary care and specialty clinics) and emergency departments. Outpatient clinics are in general a neglected practice area in antibiotic stewardship programs, yet most antibiotic use in the United States is in the outpatient setting. This article provides a comprehensive review of antibiotic stewardship strategies for outpatient UTI in the adult population, with a focus on the "five Ds" of stewardship for UTI, including right diagnosis, right drug, right dose, right duration, and de-escalation. Stewardship interventions that have shown success for improving prescribing for outpatient UTI are discussed, including diagnostic stewardship strategies, such as reflex urine cultures, computerized decision support systems, and modified reporting of urine culture results. Among the many challenges to achieving stewardship for UTI in the outpatient setting, some of the most important are diagnostic uncertainty, increasing antibiotic resistance, limitations of guidelines, and time constraints of stewardship personnel and front-line providers. This article presents a stewardship framework, built on current evidence and expert opinion, that clinicians can use to guide their own outpatient management of UTI.
Collapse
Affiliation(s)
- Melanie C. Goebel
- Section of Infectious Diseases, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Barbara W. Trautner
- Center for Innovations in Quality, Effectiveness, and Safety (IQuESt), Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, USA
- Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Larissa Grigoryan
- Department of Family and Community Medicine, Baylor College of Medicine, Houston, Texas, USA
| |
Collapse
|
26
|
Caughey AB, Krist AH, Wolff TA, Barry MJ, Henderson JT, Owens DK, Davidson KW, Simon MA, Mangione CM. USPSTF Approach to Addressing Sex and Gender When Making Recommendations for Clinical Preventive Services. JAMA 2021; 326:1953-1961. [PMID: 34694343 DOI: 10.1001/jama.2021.15731] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Clinical preventive service recommendations from the US Preventive Services Task Force (USPSTF) are based on transparent, systematic, and rigorous methods that consider the certainty of the evidence and magnitude of net benefit. These guidelines aim to address the needs of diverse populations. Biological sex and gender identity are sources of diversity that are not often considered in studies of clinical preventive services that inform the recommendations, resulting in challenges when evaluating the evidence and communicating recommendations for persons in specific gender identification categories (man/woman/gender nonbinary/gender nonconforming/transgender). To advance its methods, the USPSTF reviewed its past recommendations that included the use of sex and gender terms, reviewed the approaches of other guideline-making bodies, and pilot tested strategies to address sex and gender diversity. Based on the findings, the USPSTF intends to use an inclusive approach to identify issues related to sex and gender at the start of the guideline development process; assess the applicability, variability, and quality of evidence as a function of sex and gender; ensure clarity in the use of language regarding sex and gender; and identify evidence gaps related to sex and gender. Evidence reviews will identify the limitations of applying findings to diverse groups from underlying studies that used unclear terminology regarding sex and gender. The USPSTF will use gender-neutral language when appropriate to communicate that recommendations are inclusive of people of any gender and will clearly state when recommendations apply to individuals with specific anatomy associated with biological sex (male/female) or to specific categories of gender identity. The USPSTF recognizes limited evidence to inform the preventive care of populations based on gender identity.
Collapse
Affiliation(s)
- Aaron B Caughey
- Department of Obstetrics and Gynecology, Oregon Health & Science University, Portland
| | - Alex H Krist
- Department of Family Medicine and Population Health, Virginia Commonwealth University, Richmond
| | - Tracy A Wolff
- Center for Evidence and Practice Improvement (CEPI), Agency for Healthcare Research and Quality, Rockville, Maryland
| | - Michael J Barry
- Informed Medical Decisions Program, Division of General Internal Medicine, Massachusetts General Hospital, Boston
| | - Jillian T Henderson
- Kaiser Permanente, Northwest, Center for Health Research, Kaiser Permanente Evidence-based Practice Center, Portland, Oregon
| | - Douglas K Owens
- Stanford Health Policy, Department of Medicine and Freeman Spogli Institute for International Studies, Stanford University, Stanford, California
| | - Karina W Davidson
- Feinstein Institutes for Medical Research at Northwell Health, New York, New York
| | - Melissa A Simon
- Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Carol M Mangione
- Departments of Medicine and Health Policy and Management, University of California at Los Angeles
| |
Collapse
|
27
|
Yuill S, Velentzis LS, Smith M, Egger S, Wrede CD, Bateson D, Arbyn M, Canfell K. The impact of HPV vaccination beyond cancer prevention: effect on pregnancy outcomes. Hum Vaccin Immunother 2021; 17:3562-3576. [PMID: 34506257 PMCID: PMC8437490 DOI: 10.1080/21645515.2021.1936860] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2021] [Accepted: 05/22/2021] [Indexed: 10/20/2022] Open
Abstract
While the benefits of human papillomavirus (HPV) vaccination relating to cervical cancer prevention have been widely documented, recent published evidence is suggestive of an impact on adverse pregnancy outcomes (APOs) in vaccinated mothers and their infants, including a reduction in rates of preterm births and small for gestational age infants. In this review, we examine this evidence and the possible mechanisms by which HPV vaccination may prevent these APOs. Large-scale studies linking HPV vaccination status with birth registries are needed to confirm these results. Potential confounding factors to consider in future analyses include other risk factors for APOs, and historical changes in both the management of cervical precancerous lesions and prevention of APOs. If confirmed, these additional benefits of HPV vaccination in reducing APO rates will be of global significance, due to the substantial health, social and economic costs associated with APOs, strengthening the case for worldwide HPV immunization.
Collapse
Affiliation(s)
- Susan Yuill
- Daffodil Centre, The University of Sydney, A Joint Venture with Cancer Council NSW, Sydney, Australia
- School of Public Health, University of Sydney, Sydney, Australia
| | - Louiza S. Velentzis
- Daffodil Centre, The University of Sydney, A Joint Venture with Cancer Council NSW, Sydney, Australia
- Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Victoria, Australia
| | - Megan Smith
- Daffodil Centre, The University of Sydney, A Joint Venture with Cancer Council NSW, Sydney, Australia
| | - Sam Egger
- Daffodil Centre, The University of Sydney, A Joint Venture with Cancer Council NSW, Sydney, Australia
| | - C. David Wrede
- Department of Oncology & Dysplasia, Royal Women’s Hospital, Melbourne, Victoria, Australia
- Department of Obstetrics and Gynaecology, Melbourne Medical School, University of Melbourne, Melbourne, Victoria, Australia
| | - Deborah Bateson
- Family Planning NSW, Australia
- Discipline of Obstetrics, Gynaecology & Neonatology, Faculty of Medicine and Health, The University of Sydney School of Medicine, Sydney, Australia
| | - Marc Arbyn
- Unit Cancer Epidemiology, Belgian Cancer Centre, Sciensano, Brussels, Belgium
- Department of Human Structure and Repair, Faculty of Medicine and Health Sciences, University of Ghent, Ghent, Belgium
| | - Karen Canfell
- Daffodil Centre, The University of Sydney, A Joint Venture with Cancer Council NSW, Sydney, Australia
| |
Collapse
|
28
|
Trautner BW. Urinary Tract Infections as a Continuum: Implications for Diagnostic and Antibiotic Stewardship. Clin Infect Dis 2021; 72:1339-1341. [PMID: 32179895 DOI: 10.1093/cid/ciaa280] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2020] [Accepted: 03/13/2020] [Indexed: 11/12/2022] Open
Affiliation(s)
- Barbara W Trautner
- Center for Quality, Effectiveness and Safety (IQuESt), Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, USA.,Section of Health Services Research, Departments of Medicine and Surgery, Baylor College of Medicine, Houston, Texas, USA
| |
Collapse
|
29
|
Ganguli I, Lupo C, Mainor AJ, Wang Q, Orav EJ, Rosenthal MB, Sequist TD, Colla CH. Assessment of Prevalence and Cost of Care Cascades After Routine Testing During the Medicare Annual Wellness Visit. JAMA Netw Open 2020; 3:e2029891. [PMID: 33306120 PMCID: PMC7733154 DOI: 10.1001/jamanetworkopen.2020.29891] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
IMPORTANCE For healthy adults, routine testing during annual check-ups is considered low value and may trigger cascades of medical services of unclear benefit. It is unknown how often routine tests are performed during Medicare annual wellness visits (AWVs) or whether they are associated with cascades of care. OBJECTIVE To estimate the prevalence of routine electrocardiograms (ECGs), urinalyses, and thyrotropin tests and of cascades (further tests, procedures, visits, hospitalizations, and new diagnoses) that might follow among healthy adults receiving AWVs. DESIGN, SETTING, AND PARTICIPANTS Observational cohort study using fee-for-service Medicare claims data from beneficiaries aged 66 years and older who were continuously enrolled in fee-for-service Medicare between January 1, 2013, and March 31, 2015; received an AWV in 2014; had no test-relevant prior conditions; did not receive 1 of the 3 tests in the 6 months before the AWV; and had no test-relevant symptoms or conditions in the AWV testing period. Data were analyzed from February 13, 2019, to June 8, 2020. EXPOSURE Receipt of a given test within 1 week before or after the AWV. MAIN OUTCOMES AND MEASURES Prevalence of routine tests during AWVs and cascade-attributable event rates and associated spending in the 90 days following the AWV test period. Patient, clinician, and area-level characteristics associated with receiving routine tests were also assessed. RESULTS Among 75 275 AWV recipients (mean [SD] age, 72.6 [6.1] years; 48 107 [63.9%] women), 18.6% (14 017) received at least 1 low-value test including an ECG (7.2% [5421]), urinalysis (10.0% [7515]), or thyrotropin test (8.7% [6534]). Patients were more likely to receive a low-value test if they were younger (adjusted odds ratio [aOR], 1.69 for ages 66-74 years vs ages ≥85 years [95% CI, 1.53-1.86]), White (aOR, 1.32 compared with Black [95% CI, 1.16-1.49]), lived in urban areas (aOR, 1.29 vs rural [95% CI, 1.15-1.46]), and lived in high-income areas (aOR, 1.26 for >400% of the federal poverty level vs <200% of the federal poverty level [95% CI, 1.16-1.37]). A total of 6.1 (95% CI, 4.8-7.5) cascade-attributable events per 100 beneficiaries occurred in the 90 days following routine ECGs and 5.4 (95% CI, 4.2-6.5) following urinalyses, with cascade-attributable cost per beneficiary of $9.62 (95% CI, $6.43-$12.80) and $7.46 (95% CI, $5.11-$9.81), respectively. No cascade-attributable events or costs were found to be associated with thyrotropin tests. CONCLUSIONS AND RELEVANCE In this study, 19% of healthy Medicare beneficiaries received routine low-value ECGs, urinalyses, or thyrotropin tests during their AWVs, more often those who were younger, White, and lived in urban, high-income areas. ECGs and urinalyses were associated with cascades of modest but notable cost.
Collapse
Affiliation(s)
- Ishani Ganguli
- Harvard Medical School, Boston, Massachusetts
- Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Claire Lupo
- Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Alexander J. Mainor
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
| | - Qianfei Wang
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
| | - E. John Orav
- Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital, Boston, Massachusetts
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Meredith B. Rosenthal
- Department of Health Care Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Thomas D. Sequist
- Harvard Medical School, Boston, Massachusetts
- Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital, Boston, Massachusetts
- Mass General Brigham, Boston, Massachusetts
| | - Carrie H. Colla
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
- Norris Cotton Cancer Center, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| |
Collapse
|
30
|
Petty LA, Vaughn VM, Flanders SA, Patel T, Malani AN, Ratz D, Kaye KS, Pogue JM, Dumkow LE, Thyagarajan R, Hsaiky LM, Osterholzer D, Kronick SL, McLaughlin E, Gandhi TN. Assessment of Testing and Treatment of Asymptomatic Bacteriuria Initiated in the Emergency Department. Open Forum Infect Dis 2020; 7:ofaa537. [PMID: 33324723 PMCID: PMC7724506 DOI: 10.1093/ofid/ofaa537] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Accepted: 10/29/2020] [Indexed: 02/04/2023] Open
Abstract
Background Reducing antibiotic use in patients with asymptomatic bacteriuria (ASB) has been inpatient focused. However, testing and treatment is often started in the emergency department (ED). Thus, for hospitalized patients with ASB, we sought to identify patterns of testing and treatment initiated by emergency medicine (EM) clinicians and the association of treatment with outcomes. Methods We conducted a 43-hospital, cohort study of adults admitted through the ED with ASB (February 2018-February 2020). Using generalized estimating equation models, we assessed for (1) factors associated with antibiotic treatment by EM clinicians and, after inverse probability of treatment weighting, (2) the effect of treatment on outcomes. Results Of 2461 patients with ASB, 74.4% (N = 1830) received antibiotics. The EM clinicians ordered urine cultures in 80.0% (N = 1970) of patients and initiated treatment in 68.5% (1253 of 1830). Predictors of EM clinician treatment of ASB versus no treatment included dementia, spinal cord injury, incontinence, urinary catheter, altered mental status, leukocytosis, and abnormal urinalysis. Once initiated by EM clinicians, 79% (993 of 1253) of patients remained on antibiotics for at least 3 days. Antibiotic treatment was associated with a longer length of hospitalization (mean 5.1 vs 4.2 days; relative risk = 1.16; 95% confidence interval, 1.08-1.23) and Clostridioides difficile infection (CDI) (0.9% [N = 11] vs 0% [N = 0]; P = .02). Conclusions Among hospitalized patients ultimately diagnosed with ASB, EM clinicians commonly initiated testing and treatment; most antibiotics were continued by inpatient clinicians. Antibiotic treatment was not associated with improved outcomes, whereas it was associated with prolonged hospitalization and CDI. For best impact, stewardship interventions must expand to the ED.
Collapse
Affiliation(s)
- Lindsay A Petty
- Internal Medicine, Division of Infectious Diseases, University of Michigan, Ann Arbor, Michigan, USA
| | - Valerie M Vaughn
- Internal Medicine, Division of General Internal Medicine, University of Utah Medical School, Salt Lake City, Utah, USA
| | - Scott A Flanders
- Internal Medicine, Division of Hospital Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Twisha Patel
- Department of Pharmacy, University of Michigan, Ann Arbor, Michigan, USA
| | - Anurag N Malani
- Internal Medicine, Division of Infectious Diseases, St. Joseph Mercy Health System, Ann Arbor, Michigan, USA
| | - David Ratz
- Internal Medicine, Division of Hospital Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Keith S Kaye
- Internal Medicine, Division of Infectious Diseases, University of Michigan, Ann Arbor, Michigan, USA
| | - Jason M Pogue
- Department of Pharmacy, University of Michigan, Ann Arbor, Michigan, USA
| | - Lisa E Dumkow
- Department of Pharmacy, Mercy Health Saint Mary's, Grand Rapids, Michigan, USA
| | | | - Lama M Hsaiky
- Department of Pharmacy, Beaumont Hospital, Dearborn, Michigan, USA
| | - Danielle Osterholzer
- Internal Medicine, Division of Infectious Diseases, Hurley Medical Center, Flint, Michigan, USA
| | - Steven L Kronick
- Department of Emergency Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Elizabeth McLaughlin
- Internal Medicine, Division of Hospital Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Tejal N Gandhi
- Internal Medicine, Division of Infectious Diseases, University of Michigan, Ann Arbor, Michigan, USA
| |
Collapse
|
31
|
Goebel MC, Trautner BW, Wang Y, Van JN, Dillon LM, Patel PK, Drekonja DM, Graber CJ, Shukla BS, Lichtenberger P, Helfrich CD, Sales A, Grigoryan L. Organizational readiness assessment in acute and long-term care has important implications for antibiotic stewardship for asymptomatic bacteriuria. Am J Infect Control 2020; 48:1322-1328. [PMID: 32437753 DOI: 10.1016/j.ajic.2020.04.024] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Revised: 04/29/2020] [Accepted: 04/30/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND Prior to implementing an antibiotic stewardship intervention for asymptomatic bacteriuria (ASB), we assessed institutional barriers to change using the Organizational Readiness to Change Assessment. METHODS Surveys were self-administered on paper in inpatient medicine and long-term care units at 4 Veterans Affairs facilities. Participants included providers, nurses, and pharmacists. The survey included 7 subscales: evidence (perceived strength of evidence) and six context subscales (favorability of organizational context). Responses were scored on a 5-point Likert-type scale. RESULTS One hundred four surveys were completed (response rate = 69.3%). Overall, the evidence subscale had the highest score; the resources subscale (mean 2.8) was significantly lower than other subscales (P < .001). Scores for budget and staffing resources were lower than scores for training and facility resources (P < .001 for both). Pharmacists had lower scores than providers for the staff culture subscale (P = .04). The site with the lowest scores for resources (mean 2.4) also had lower scores for leadership and lower pharmacist effort devoted to stewardship. CONCLUSIONS Although healthcare professionals endorsed the evidence about nontreatment of ASB, perceived barriers to antibiotic stewardship included inadequate resources and leadership support. These findings provide targets for tailoring the stewardship intervention to maximize success.
Collapse
|
32
|
Koucky M, Kamel R, Vistejnova L, Kalis V, Ismail KM. A global perspective on management of bacterial infections in pregnancy: a systematic review of international guidelines. J Matern Fetal Neonatal Med 2020; 35:3751-3760. [PMID: 33115310 DOI: 10.1080/14767058.2020.1839879] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Maternal sepsis is a leading cause of maternal and neonatal mortality. Despite the availability of management protocols, there is disparity in case fatality rates for pregnancy-related sepsis compared to other maternity-related complications. The main aim of this systematic review was to assess concordance between international evidence-based guidelines for the prevention and management of childbirth-related bacterial infections. MATERIAL AND METHODS The PRISMA statement was followed during the conduct and reporting of this review. PubMed was searched electronically from 2009 to November 2019 for clinical guidelines covering the topic of childbirth-related infections and specific searches for relevant guidelines on the websites of the top five international professional bodies most commonly identified by our searches. We did not apply any language restrictions. Guidelines were included if they provided any information about the prevention or management of childbirth-related bacterial infections irrespective of whether the guideline stated a recommendation or not. Two independent reviewers undertook study selection, decisions about inclusion of selected guidelines and data extraction. Extracted information was synthesized under the following topics: Asymptomatic bacteriuria; group B streptococcal infection (GBS); preterm premature rupture of membranes (P-PROM); intrauterine infection; procedures; maternal sepsis; miscellaneous. Concordance was defined as absence of contradictory information between the different guidelines with regards to a specific topic, subtopic or recommendation. Quality of included guidelines was assessed against the AGREE II guideline reporting domains. RESULTS A total of 43 guidelines were selected of which 11 were excluded leaving 32 guidelines that fulfilled our inclusion criteria. None of the guidelines fulfilled all the quality assessment domains and 11 (34%) of the guidelines satisfied 1-2 of domains only. Two guidelines covered the topic of asymptomatic bacteriuria, nine for GBS, five for P-PROM and three covered each of intra-amniotic infections maternal sepsis, obstetric procedures and interventions topics. The remaining guidelines covered miscellaneous topics. CONCLUSIONS There was concordance between guidelines with regards to several aspects in the prophylaxis and treatment of bacteriological infections in pregnancy. Nevertheless, there were several areas of discordance, some of which reached the extent of contradictory information as in the case of antenatal screening for GBS.
Collapse
Affiliation(s)
- Michal Koucky
- Maternal-Fetal Medicine Unit, Department of Obstetrics and Gynecology, 1st Faculty of Medicine, Charles University and General Faculty Hospital in Prague, Prague, Czech Republic
| | - Rasha Kamel
- Maternal-Fetal Medicine Unit, Department of Obstetrics and Gynecology, Cairo University, Cairo, Egypt
| | - Lucie Vistejnova
- Biomedical center, Faculty of Medicine in Pilsen, Charles University, Pilsen, Czech Republic.,Department of Histology and Embryology, Faculty of Medicine in Pilsen, Charles University, Pilsen, Czech Republic
| | - Vladimir Kalis
- Biomedical center, Faculty of Medicine in Pilsen, Charles University, Pilsen, Czech Republic.,Department of Obstetrics and Gynecology, University Hospital, Pilsen, Czech Republic
| | - Khaled M Ismail
- Biomedical center, Faculty of Medicine in Pilsen, Charles University, Pilsen, Czech Republic.,Department of Gynecology and Obstetrics, Faculty of Medicine in Pilsen, Pilsen, Czech Republic
| |
Collapse
|
33
|
Poulios E, Vasios GK, Psara E, Giaginis C. Medicinal plants consumption against urinary tract infections: a narrative review of the current evidence. Expert Rev Anti Infect Ther 2020; 19:519-528. [PMID: 33016791 DOI: 10.1080/14787210.2021.1828061] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Urinary tract infections (UTIs) are usual diseases caused by different strains of microorganisms. Many antibiotics have been applied for the treatment of these infections. However, the development of multidrug-resistant strains is a major problem in these treatments. As alternative complementary agents, several medicinal plants are often used to prevent and/or treat these diseases. AREAS COVERED This review summarized the current evidence about the efficacy of medicinal plants' consumption to prevent and/or co-treat UTIs. The most precise scientific databases, e.g. Medline, Scopus, and Web of Science were comprehensively searched, using relative keywords to identify the relative in vivo and ex vivo animal and human studies. EXPERT OPINION Current studies supported evidence for potential benefit overall concerning medicinal plants' consumption against UTIs by preventing bacterial adherence and inhibiting inflammation cascades through responding immunologically to bacteria invasion. However, most of the current evidence have been focused on in vivo and ex vivo animal studies, while human studies are currently limited and did not focus on a specific medicinal plant. Thus, well-designed clinical trials for long study periods focused on individual medicinal plants are intensely recommended to delineate their effectiveness on the prevention and/or co-treatment of UTIs.
Collapse
Affiliation(s)
- Efthymios Poulios
- Department of Food Science and Nutrition, School of the Environment, University of the Aegean, Lemnos, Greece
| | - Georgios K Vasios
- Department of Food Science and Nutrition, School of the Environment, University of the Aegean, Lemnos, Greece
| | - Evmorfia Psara
- Department of Food Science and Nutrition, School of the Environment, University of the Aegean, Lemnos, Greece
| | - Constantinos Giaginis
- Department of Food Science and Nutrition, School of the Environment, University of the Aegean, Lemnos, Greece
| |
Collapse
|
34
|
Frazier RL, Huppmann AR. Educational Case: Acute Cystitis. Acad Pathol 2020; 7:2374289520951923. [PMID: 32974422 PMCID: PMC7495512 DOI: 10.1177/2374289520951923] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Revised: 07/09/2020] [Accepted: 07/17/2020] [Indexed: 11/24/2022] Open
Abstract
The following fictional case is intended as a learning tool within the
Pathology Competencies for Medical Education (PCME), a set of national
standards for teaching pathology. These are divided into three basic
competencies: Disease Mechanisms and Processes, Organ System Pathology, and
Diagnostic Medicine and Therapeutic Pathology. For additional information,
and a full list of learning objectives for all three competencies,
seehttp://journals.sagepub.com/doi/10.1177/2374289517715040.1
Collapse
Affiliation(s)
- Ryan L Frazier
- Department of Pathology, School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, USA. Huppmann is now at the University of South Carolina School of Medicine Greenville, Greenville, SC, USA
| | - Alison R Huppmann
- Department of Pathology, School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, USA. Huppmann is now at the University of South Carolina School of Medicine Greenville, Greenville, SC, USA
| |
Collapse
|
35
|
Safety, effectiveness and sustainability of a laboratory intervention to de-adopt culture of midstream urine samples among hospitalized patients. Infect Control Hosp Epidemiol 2020; 42:43-50. [PMID: 32873350 DOI: 10.1017/ice.2020.385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVE To assess the safety, sustainability, and effectiveness of a laboratory intervention to reduce processing of midstream urine (MSU) cultures. DESIGN Prospective observational cohort. SETTING Medical and surgical inpatients in a tertiary-care hospital. PARTICIPANTS The study included 1,678 adult inpatients with an order for MSU culture. METHODS From 2013 to 2019, ordered MSU cultures were not processed unless the laboratory was called. Patients were interviewed on days 0 and 4; from 2017 to 2019, day-30 follow-up was added. Primary outcome was serious adverse events due to not processing MSU cultures. Secondary outcomes were nonserious adverse events due to not processing MSU cultures, rates of MSU cultures submitted, proportion of MSU cultures processed, proportion of patients prescribed urinary tract infection (UTI)-directed antibiotics, and laboratory workload. RESULTS Among 912 and 459 patients followed to days 4 and 30, respectively, no serious adverse events attributable to not processing MSU cultures were identified. However, 6 patients (0.66%) had prolonged urinary symptoms potentially associated with not processing MSU cultures. We estimated that 4 patients missed having empiric antibiotics stopped in response to negative MSU cultures, and 99 antibiotic courses for asymptomatic bacteriuria (ASB) and 8 antibiotic-associated adverse events were avoided. The rate of submitted MSU samples and proportion of patients receiving empiric UTI-directed antibiotics did not change. The proportion of MSU cultures processed declined from 59% to 49% (P < .0001), and total laboratory workload was reduced by 185 hours. CONCLUSIONS De-adopting the processing of MSU cultures from medical and surgical inpatient units is safe and sustainable, and it reduces antibiotic prescriptions for ASB at a cost of prolonged urinary symptoms in a small proportion of patients.
Collapse
|
36
|
Peng Z, Hayen A, Hall J, Liu B. Microbiology testing and antibiotic treatment for urinary tract infections in general practice: a nationwide observational study. Infection 2020; 49:249-255. [PMID: 32862305 DOI: 10.1007/s15010-020-01512-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Accepted: 08/20/2020] [Indexed: 11/26/2022]
Abstract
PURPOSE Routine urine testing is recommended prior to antibiotic treatment for urinary tract infections (UTIs) among high-risk groups for complicated UTIs. This study aims to examine whether the proportion of UTI encounters where antibiotics are prescribed that have accompanying urine testing differs by patient groups. METHODS A retrospective analysis was conducted using records of general practice encounters for UTIs occurring between January 2013 and July 2018 in an Australian national database. We calculated the proportion of UTI encounters with antibiotics prescribed that had accompanying urine microbiology testing and the odds ratios for the likelihood of testing by patient groups using generalised estimating equations. RESULTS Of 132,688 UTI encounters with antibiotics prescribed, 95,800 (72.2%) were accompanied by urine testing. Among high-risk groups for complicated UTIs and expected to have a high likelihood of testing, we found pregnant women [82.6% vs. non-pregnant 72.3%, adjusted odds ratio (aOR) 1.82, 95% confidence intervals (CI) 1.55-2.12] and children aged 5-9 years (77.6% vs. 20-44 years 72.0%, aOR 1.33, 95% CI 1.22-1.45) had relatively high odds of testing. However, children aged < 5 years (68.7% vs. 20-44 years 72.0%, aOR 0.83, 95% CI 0.76-0.90), patients with recurrent UTIs (69.0% compared to first-onset UTIs 73.6%, aOR 0.81, 95% CI 0.79-0.83), and patients in residential aged care facilities (67.3% vs. not 72.3%, aOR 0.80, 95% CI 0.72-0.90) had relatively low odds of testing. CONCLUSION Our results suggest inconsistencies and potential underuse of urine testing when antibiotics were prescribed for high-risk groups in UTI management. Further antibiotic stewardship is needed to improve guideline-based antibiotic prescribing for UTIs.
Collapse
Affiliation(s)
- Zhuoxin Peng
- School of Public Health and Community Medicine, University of New South Wales, Sydney, NSW, 2052, Australia.
| | - Andrew Hayen
- School of Public Health, Faculty of Health, University of Technology Sydney, Sydney, NSW, Australia
| | - John Hall
- School of Public Health and Community Medicine, University of New South Wales, Sydney, NSW, 2052, Australia
| | - Bette Liu
- School of Public Health and Community Medicine, University of New South Wales, Sydney, NSW, 2052, Australia
| |
Collapse
|
37
|
Abstract
OBJECTIVE Administration of antimicrobials to patients with asymptomatic bacteriuria (ASB) is a common error that can lead to worse outcomes. However, controlled analyses quantifying the commonality and impact of this practice are lacking. We analyzed the independent predictors for antimicrobials misuse in ASB and quantified the impact of this practice on clinical outcomes. DESIGN Retrospective case-control and cohort analyses for calendar year 2017. SETTING Tertiary-care, university-affiliated medical center. PATIENTS The study included adult (>18 years) patients with positive urine culture. Pregnant women, renal transplant recipients, and patients who underwent urologic procedures were excluded. METHODS ASB was determined according to US Centers for Disease Control and Prevention (CDC) criteria. Multivariable logistic regression models were constructed to analyze predictors and outcomes associated with antimicrobial use for patients with ASB. RESULTS The study included 1,530 patient-unique positive urine cultures. Among these patients, 610 patients (40%) were determined to have ASB. Of the 696 isolates, 219 (36%) were multidrug-resistant organisms (MDROs). Also, 178 (29%) patients received antimicrobials specifically due to the ASB. Independent predictors for improper administration of antimicrobials were dependent functional status (adjusted odds ratio [aOR], 2.3; 95% CI, 1.4-3.6) and male sex (aOR, 2; 95% CI, 1.25-2.6). Use of antimicrobials was independently associated with re-hospitalizations (aOR, 1.7; 95% CI, 1.1-2.6) and later, acute Clostridioides difficile infections (CDI) in the following 90 days (aOR, 4.5; 95% CI, 2-10.6). CONCLUSIONS ASB is a common condition, frequently resulting from an MDRO. Male sex and poor functional status were independent predictors for mistreatment, and this practice was independently associated with rehospitalizations and CDI in the following 90 days.
Collapse
|
38
|
Schuler F, Froböse N, Schaumburg F. Prevalence and risk factors for bacteremia in patients with Staphylococcus aureus bacteriuria: A retrospective cohort study. Int J Infect Dis 2020; 98:467-469. [PMID: 32717397 DOI: 10.1016/j.ijid.2020.07.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Revised: 07/15/2020] [Accepted: 07/21/2020] [Indexed: 02/04/2023] Open
Abstract
OBJECTIVES Staphylococcus aureus bacteriuria (SABU) is rare but can be an indicator of S. aureus bacteremia (SAB). The objective of this study was to assess the proportion of SAB in patients with SABU and identify risk factors in a hospital-based population. METHODS We used electronic databases to identify eligible patients to be enrolled in a retrospective cohort study. Inclusion criteria were (i) SABU, (ii) ≥18 years of age, and (iii) ≥1 blood culture sampled ±3 months of SABU. Patients with missing values for demographic (e.g., age, sex) or clinical characteristics (e.g., comorbidities) and laboratory analyses were excluded. RESULTS In total, 245 patients attending the University Hospital Münster, Germany, between 1 January 2012 and 31 December 2019 met the inclusion/exclusion criteria. Of the 245 patients with SABU, 66 had a concomitant SAB (26.9%). Elevated C-reactive protein (CRP) levels were associated with SAB. Other parameters (e.g., leukocytes, comorbidities) were not associated with SAB in a multivariate analysis. CONCLUSION The frequency of SAB in patients with SABU was high and warrants active screening for bloodstream infections in hospitalized patients, particularly if CRP levels are elevated.
Collapse
Affiliation(s)
- Franziska Schuler
- Institute of Medical Microbiology, University Hospital Münster, Münster, Germany
| | - Neele Froböse
- Institute of Medical Microbiology, University Hospital Münster, Münster, Germany
| | - Frieder Schaumburg
- Institute of Medical Microbiology, University Hospital Münster, Münster, Germany.
| |
Collapse
|
39
|
|
40
|
|
41
|
de Rossi P, Cimerman S, Truzzi JC, Cunha CAD, Mattar R, Martino MDV, Hachul M, Andriolo A, Vasconcelos Neto JA, Pereira-Correia JA, Machado AMO, Gales AC. Joint report of SBI (Brazilian Society of Infectious Diseases), FEBRASGO (Brazilian Federation of Gynecology and Obstetrics Associations), SBU (Brazilian Society of Urology) and SBPC/ML (Brazilian Society of Clinical Pathology/Laboratory Medicine): recommendations for the clinical management of lower urinary tract infections in pregnant and non-pregnant women. Braz J Infect Dis 2020; 24:110-119. [PMID: 32360431 PMCID: PMC9392033 DOI: 10.1016/j.bjid.2020.04.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2020] [Revised: 03/31/2020] [Accepted: 04/01/2020] [Indexed: 11/11/2022] Open
Abstract
Urinary tract infection (UTI) is a common condition in women. There is an increased concern on reduction of bacterial susceptibility resulting from wrongly prescribing antimicrobials. This paper summarizes the recommendations of four Brazilian medical societies (SBI – Brazilian Society of Infectious Diseases, FEBRASGO – Brazilian Federation of Gynecology and Obstetrics Associations, SBU – Brazilian Society of Urology, and SBPC/ML – Brazilian Society of Clinical Pathology/Laboratory Medicine) on the management of urinary tract infection in women. Asymptomatic bacteriuria should be screened at least twice during pregnancy (early and in the 3rd trimester). All cases of significant bacteriuria (≥105 CFU/mL in middle stream sample) should be treated with antimicrobials considering safety and susceptibility profile. In women with typical symptoms of cystitis, dipsticks are not necessary for diagnosis. Urine cultures should be collected in pregnant women, recurrent UTI, atypical cases, and if there is suspicion of pyelonephritis. First line antimicrobials for cystitis are fosfomycin trometamol in a single dose and nitrofurantoin, 100 mg every 6 hours for five days. Second line drugs are cefuroxime or amoxicillin-clavulanate for seven days. During pregnancy, amoxicillin and other cephalosporins may be used, but with a higher chance of therapeutic failure. In recurrent UTI, all episodes should be confirmed by urine culture. Treatment should be initiated only after urine sampling and with the same regimens indicated for isolated episodes. Prophylaxis options of recurrent UTI are behavioral measures, non-antimicrobial and antimicrobial prophylaxis. Vaginal estrogens may be recommended for postmenopausal women. Other non-antimicrobial prophylaxis, including cranberry and immunoprophylaxis, have weak evidence supporting their use. Antimicrobial prophylaxis may be offered as a continuous or postcoital scheme. In pregnant women, options are cephalexin, 250–500 mg and nitrofurantoin, 100 mg (contraindicated after 37 weeks of pregnancy). Nonpregnant women may use fosfomycin trometamol, 3 g every 10 days, or nitrofurantoin, 100 mg (continuous or postcoital).
Collapse
Affiliation(s)
- Patricia de Rossi
- Conjunto Hospitalar do Mandaqui and Federação Brasileira das Associações de Ginecologia e Obstetrícia (FEBRASGO), São Paulo, SP, Brazil.
| | - Sergio Cimerman
- Instituto de Infectologia Emílio Ribas, São Paulo, SP, Brazil
| | - José Carlos Truzzi
- Universidade Federal de São Paulo (UNIFESP) and Instituto do Câncer Arnaldo Vieira de Carvalho (IAVC), São Paulo, SP, Brazil
| | | | - Rosiane Mattar
- Universidade Federal de São Paulo (UNIFESP), Escola Paulista de Medicina (EPM), Departamento de Obstetrícia, São Paulo, SP, Brazil
| | - Marinês Dalla Valle Martino
- Faculdade de Ciências Médicas da Santa Casa de São Paulo and Hospital Israelita Albert Einstein (HIAE), São Paulo, SP, Brazil
| | - Maurício Hachul
- Sociedade Brasileira de Urologia (SBU), São Paulo, SP, Brazil
| | - Adagmar Andriolo
- Universidade Federal de São Paulo (UNIFESP), Escola Paulista de Medicina (EPM), São Paulo, SP, Brazil
| | | | - João Antônio Pereira-Correia
- Serviço de Urologia do Hospital dos Servidores do Estado do Rio de Janeiro and Departamento de Urologia Feminina da Sociedade Brasileira de Urologia (SBU), Rio de Janeiro, RJ, Brazil
| | - Antonia M O Machado
- Universidade Federal de São Paulo (UNIFESP), Hospital São Paulo, Escola Paulista de Medicina (EPM), São Paulo, SP, Brazil
| | - Ana Cristina Gales
- Universidade Federal de São Paulo (UNIFESP), Escola Paulista de Medicina (EPM), Departamento de Medicina, São Paulo, SP, Brazil
| |
Collapse
|
42
|
Targeting Asymptomatic Bacteriuria in Antimicrobial Stewardship: the Role of the Microbiology Laboratory. J Clin Microbiol 2020; 58:JCM.00518-18. [PMID: 32051261 DOI: 10.1128/jcm.00518-18] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
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.
Collapse
|
43
|
Skelton F, May S, Grigoryan L, Poon I, Holmes SA, Martin L, Trautner BW. Spinal Cord Injury Provider Knowledge and Attitudes Toward Bacteriuria Management and Antibiotic Stewardship. PM R 2020; 12:1187-1194. [PMID: 32304350 DOI: 10.1002/pmrj.12384] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Revised: 02/23/2020] [Accepted: 04/03/2020] [Indexed: 11/09/2022]
Abstract
INTRODUCTION Bacteriuria, either asymptomatic or urinary tract infection, is common in persons with spinal cord injury or disorder (SCI/D). In the Veterans Health Administration (VHA), conflicting clinical practice guidelines make appropriate bacteriuria management and antibiotic stewardship challenging. OBJECTIVE To explore SCI/D provider knowledge, attitudes, and teamwork around bacteriuria management during the VHA SCI/D annual examination. DESIGN Mixed methods. SETTING VHA SCI/D centers. PARTICIPANTS SCI/D staff providers and physical medicine and rehabilitation resident physicians. MAIN OUTCOME MEASUREMENTS Knowledge, safety, and teamwork scores on bacteriuria management using a validated questionnaire. Themes on barriers and facilitators to bacteriuria management during the SCI/D annual exam, and attitudes toward antibiotic stewardship in general. RESULTS We received 84 responses from 344 distributed surveys, with a response rate of 24%. Thirty percent of all participants endorsed incorrect triggers for obtaining a urine culture (change in urine color, cloudiness, or odor). The type of organism identified on culture drove unnecessary antibiotic use; 57% would treat asymptomatic bacteriuria if caused by extended spectrum beta-lactamase Escherichia coli. There were no significant differences between the median (interquartile range [IQR]) knowledge score of the staff providers (70.6 [58.8-82.4]) and the resident physicians (64.7 [58.8-82.4]), but the teamwork climate scores (P = .02) and safety climate scores (P < .01) were higher among staff providers than among resident physicians. Interview analysis identified how the limited recall of content among SCI/D providers of the guidelines for bacteriuria was a potential barrier to their use but attitudes toward guidelines and antibiotic stewardship initiatives were positive. CONCLUSION All participants objectively demonstrated actionable gaps in bacteriuria management and expressed uncertainty in their knowledge during qualitative interviews. Through addressing these gaps, we can develop effective antibiotic stewardship programs for the VHA SCI/D system of care.
Collapse
Affiliation(s)
- Felicia Skelton
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston, TX, USA.,H. Ben Taub Department of Physical Medicine and Rehabilitation, Baylor College of Medicine, Houston, TX, USA
| | - Sarah May
- Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Larissa Grigoryan
- Department of Family and Community Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Ivy Poon
- Department of Pharmacy Practice, Texas Southern University, Houston, TX, USA
| | - Sally Ann Holmes
- H. Ben Taub Department of Physical Medicine and Rehabilitation, Baylor College of Medicine, Houston, TX, USA
| | - Lindsey Martin
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston, TX, USA.,Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Barbara W Trautner
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston, TX, USA.,Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| |
Collapse
|
44
|
Owens DK, Davidson KW, Krist AH, Barry MJ, Cabana M, Caughey AB, Donahue K, Doubeni CA, Epling JW, Kubik M, Ogedegbe G, Pbert L, Silverstein M, Simon MA, Tseng CW, Wong JB. Screening for Bacterial Vaginosis in Pregnant Persons to Prevent Preterm Delivery: US Preventive Services Task Force Recommendation Statement. JAMA 2020; 323:1286-1292. [PMID: 32259236 DOI: 10.1001/jama.2020.2684] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Bacterial vaginosis is common and is caused by a disruption of the microbiological environment in the lower genital tract. In the US, reported prevalence of bacterial vaginosis among pregnant women ranges from 5.8% to 19.3% and is higher in some races/ethnicities. Bacterial vaginosis during pregnancy has been associated with adverse obstetrical outcomes including preterm delivery, early miscarriage, postpartum endometritis, and low birth weight. OBJECTIVE To update its 2008 recommendation, the USPSTF commissioned a review of the evidence on the accuracy of screening and the benefits and harms of screening for and treatment of bacterial vaginosis in asymptomatic pregnant persons to prevent preterm delivery. POPULATION This recommendation applies to pregnant persons without symptoms of bacterial vaginosis. EVIDENCE ASSESSMENT The USPSTF concludes with moderate certainty that screening for asymptomatic bacterial vaginosis in pregnant persons not at increased risk for preterm delivery has no net benefit in preventing preterm delivery. The USPSTF concludes that for pregnant persons at increased risk for preterm delivery, the evidence is conflicting and insufficient, and the balance of benefits and harms cannot be determined. CONCLUSIONS AND RECOMMENDATION The USPSTF recommends against screening for bacterial vaginosis in pregnant persons not at increased risk for preterm delivery. (D recommendation) The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for bacterial vaginosis in pregnant persons at increased risk for preterm delivery. (I statement).
Collapse
Affiliation(s)
| | - Douglas K Owens
- Veterans Affairs Palo Alto Health Care System, Palo Alto, California
- Stanford University, Stanford, California
| | - Karina W Davidson
- Feinstein Institute for Medical Research at Northwell Health, Manhasset, New York
| | - Alex H Krist
- Fairfax Family Practice Residency, Fairfax, Virginia
- Virginia Commonwealth University, Richmond
| | | | | | | | | | | | | | | | | | - Lori Pbert
- University of Massachusetts Medical School, Worcester
| | | | | | - Chien-Wen Tseng
- University of Hawaii, Honolulu
- Pacific Health Research and Education Institute, Honolulu, Hawaii
| | - John B Wong
- Tufts University School of Medicine, Boston, Massachusetts
| |
Collapse
|
45
|
Nteziyaremye J, Iramiot SJ, Nekaka R, Musaba MW, Wandabwa J, Kisegerwa E, Kiondo P. Asymptomatic bacteriuria among pregnant women attending antenatal care at Mbale Hospital, Eastern Uganda. PLoS One 2020; 15:e0230523. [PMID: 32191758 PMCID: PMC7082119 DOI: 10.1371/journal.pone.0230523] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Accepted: 03/02/2020] [Indexed: 11/18/2022] Open
Abstract
Background Asymptomatic bacteriuria in pregnancy (ASBP) is associated with adverse pregnancy outcomes such as pyelonephritis, preterm or low birth weight delivery if untreated. The aim of this study was to determine the prevalence of asymptomatic bacteriuria, the isolated bacterial agents, and their antibiotic sensitivity patterns in pregnant women attending antenatal care at Mbale Hospital. Methods This was a cross sectional study in which 587 pregnant women with no symptoms and signs of urinary tract infection were recruited from January to March 2019. Mid-stream clean catch urine samples were collected from the women using sterile containers. The urine samples were cultured using standard laboratory methods. The bacterial colonies were identified and antibiotic sensitivity was done using disc diffusion method. Chi squared tests and logistic regression were done to identify factors associated with asymptomatic bacteriuria. A p value < 0.05 was considered statistically significant. Results Out of the 587 pregnant women, 22 (3.75%) tested positive for asymptomatic bacteriuria. Women aged 20–24 years were less likely to have ASBP when compared to women aged less than 20 years (AOR = 0.14, 95%CI 0.02–0.95, P = 0.004). The most common isolates in descending order were E. coli (n = 13, 46.4%) and S.aureus (n = 9, 32.1%). Among the gram negative isolates, the highest sensitivity was to gentamycin (82.4%) and imipenem (82.4%). The gram positive isolates were sensitive to gentamycin (90.9%) followed by imipenem (81.8%). All the isolates were resistant to sulphamethoxazole with trimethoprim (100%). Multidrug resistance was 82.4% among gram negative isolates and 72.4% among the gram positive isolates. Conclusion There was high resistance to the most commonly used antibiotics. There is need to do urine culture and sensitivity from women with ASBP so as to reduce the associated complications.
Collapse
Affiliation(s)
- Julius Nteziyaremye
- Department of Obstetrics and Gynecology, College of Health Sciences, Makerere University, Kampala, Uganda
- Department of Obstetrics and Gynecology, Faculty of Health Sciences, Busitema University, Mbale, Uganda
| | - Stanley Jacob Iramiot
- Department of Microbiology and Immunology, Faculty of Health Sciences, Busitema University, Mbale, Uganda
| | - Rebecca Nekaka
- Department of Community and Public Health, Faculty of Health Sciences, Busitema University, Mbale, Uganda
| | - Milton W. Musaba
- Department of Obstetrics and Gynecology, Faculty of Health Sciences, Busitema University, Mbale, Uganda
| | - Julius Wandabwa
- Department of Obstetrics and Gynecology, Faculty of Health Sciences, Busitema University, Mbale, Uganda
| | - Enoch Kisegerwa
- Department of Obstetrics and Gynecology, Mulago Hospital, Kampala, Uganda
| | - Paul Kiondo
- Department of Obstetrics and Gynecology, College of Health Sciences, Makerere University, Kampala, Uganda
- * E-mail:
| |
Collapse
|
46
|
Schafer R, Phillippi JC. Group B Streptococcal Bacteriuria in Pregnancy: An Evidence-Based, Patient-Centered Approach to Care. J Midwifery Womens Health 2020; 65:376-381. [PMID: 32096338 DOI: 10.1111/jmwh.13085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2017] [Revised: 12/10/2019] [Accepted: 12/17/2019] [Indexed: 11/29/2022]
Abstract
Screening and management of group B streptococcus (GBS) bacteriuria in pregnancy aims to reduce the incidence of pyelonephritis and GBS-related neonatal morbidity and mortality. Universal screening and management of GBS bacteriuria in pregnancy are standards of care in the United States; however, some women may decline guideline-based recommendations for screening, treatment, or intrapartum antibiotic prophylaxis. This article uses a case study approach to discuss evidence-based, patient-centered care for GBS bacteriuria in pregnancy as well as ethical incorporation of individual patient preferences and values.
Collapse
Affiliation(s)
- Robyn Schafer
- Rutgers University School of Nursing, Newark, New Jersey
| | | |
Collapse
|