Antimicrobial Stewardship and Urinary Tract Infections

Improving Empiric Antibiotic Selection for Patients Hospitalized With Abdominal Infection: The INSPIRE 4 Cluster Randomized Clinical Trial

Importance

Empiric extended-spectrum antibiotics are routinely prescribed for over a million patients hospitalized annually with abdominal infection despite low likelihoods of infection with multidrug-resistant organisms (MDROs).

Objective

To evaluate whether computerized provider order entry (CPOE) prompts providing patient- and pathogen-specific MDRO infection risk estimates can reduce empiric extended-spectrum antibiotics for non-critically ill patients admitted with abdominal infection.

Design, Setting, and Participants

This 92-hospital cluster randomized clinical trial assessed the effect of an antibiotic stewardship bundle with CPOE prompts vs routine stewardship on antibiotic selection during the first 3 hospital days (empiric period) in non-critically ill adults hospitalized with abdominal infection. The trial population included adults (≥18 years) treated with empiric antibiotics for abdominal infection in non-intensive care units (ICUs). The trial periods included a 12-month baseline from January to December 2019 and an intervention period from January to December 2023.

Intervention

CPOE prompts recommending standard-spectrum antibiotics in patients prescribed extended-spectrum antibiotics during the empiric period if the patient's estimated absolute risk of MDRO abdominal infection was less than 10%, coupled with feedback and education.

Main Outcomes and Measures

The primary outcome was empiric extended-spectrum antibiotic days of therapy. Safety outcomes: days to ICU transfer and hospital length of stay. Analyses compared differences between baseline and intervention periods across strategies.

Results

Among 92 hospitals with 198 480 patients, mean (SD) age was 60 (19) years and 118 723 (59.8%) were female. The trial included 93 476 and 105 004 patients hospitalized with abdominal infection during the baseline and intervention periods, respectively. Receipt of any empiric extended-spectrum antibiotics for the routine care group was 48.2% (22 519 of 46 725) during baseline and 50.5% (27 452 of 54 384) during intervention vs 47.8% (22 367 of 46 751) and 37.6% (19 010 of 50 620) for the CPOE bundle group. The group receiving CPOE prompts had a 35% relative reduction (rate ratio, 0.65; 95% CI, 0.60-0.71; P < .001) in empiric extended-spectrum antibiotic days of therapy vs routine care (raw absolute reduction between baseline and intervention periods was -169 for the CPOE bundle vs -20 for routine care). Hospital length of stay was noninferior to routine care (0.1 days longer during intervention; mean [SD], baseline, 5.4 [3.4] days vs intervention, 5.5 [3.5] days; hazard ratio [HR], 1.02; 90% CI, 0.99-1.06), and mean days to ICU transfer in the CPOE group was indeterminate (both groups 0.2 days longer during intervention; HR, 1.10; 90% CI, 0.99-1.23).

Conclusions and Relevance

CPOE prompts recommending empiric standard-spectrum antibiotics (coupled with education and feedback) for patients admitted with abdominal infection who have low risk for MDRO infection significantly reduced extended-spectrum antibiotics without increasing ICU transfers or length of stay.

Trial Registration

ClinicalTrials.gov Identifier: NCT05423743.

Risk Factors for Empiric Treatment Failure in US Female Outpatients with Uncomplicated Urinary Tract Infection: an Observational Study

BACKGROUND

Treatment failure (TF) in uncomplicated urinary tract infection (uUTI) increases disease burden and risk of antimicrobial resistance. Identification of risk factors for TF could inform empiric treatment decisions and reduce suboptimal outcomes.

OBJECTIVE

To evaluate the incidence of TF to empirically prescribed oral antibiotics and identify risk factors for TF in females with uUTI in the United States (US).

DESIGN

This retrospective cohort study used Optum's de-identified Electronic Health Record dataset (January 2017-September 2022).

PATIENTS

Eligible female patients aged ≥ 12 years had ≥ 1 diagnosis of urinary tract infection (UTI) in an outpatient ambulatory/emergency department (ED) setting, ≥ 1 empiric oral antibiotic prescription, and no evidence of complicated UTI (cUTI).

MAIN MEASURES

TF was defined as having a new/repeat oral antibiotic prescription, IV antibiotic administration or acute UTI diagnosis ≤ 28 days following initial empiric oral antibiotic prescription​. Risk factors of TF were selected using LASSO and reported using adjusted risk ratios (aRR) and 95% CIs.

KEY RESULTS

Of 376,004 patients with uUTI, 62,873 (16.7%) experienced TF. Incidence of TF was highest in patients with history of antibiotic TF (33.9%) or fosfomycin prescription (30.1%). Significant risk factors of TF included ≥ 3 prior antibiotic prescriptions (aRR [95% CI]: 1.60 [1.56-1.64]); fosfomycin prescription (1.60 [1.38-1.86]); uUTI diagnosis in ED (1.49 [1.46-1.52]), Southern US residence (1.37 [1.35-1.40]), age ≥ 75 years (1.35 [1.29-1.41]), recurrent UTI (1.12 [1.10-1.14]) and obesity (1.06 [1.04-1.08]).

CONCLUSIONS

Incidence of TF to empirically prescribed oral antibiotics for uUTI is considerable. Prior infections requiring antibiotic prescription and location of care are key risk factors for TF in female outpatients with uUTI. Knowledge of these TF risk factors can inform shared-decision making and supplement existing guidance on uUTI treatment.

Current and emerging strategies to curb antibiotic-resistant urinary tract infections

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.

Gaps in knowledge and recurrent urinary tract infections in women

PURPOSE OF REVIEW

The focus of this review is to present recent literature and gaps in knowledge (GIKs) surrounding the current and future treatment and prevention of uncomplicated recurrent urinary tract infections (rUTIs) in women.

RECENT FINDINGS

Recurrent urinary tract infections are common, significantly reduce quality of life, and create a substantial economic burden to the healthcare system. They are disproportionately affecting the postmenopausal women. Antibiotics, which are used for the treatment and prophylaxis of uncomplicated rUTI, have become problematic, as there is a global rise in allergy and resistance to these agents and their use is associated with further antimicrobial resistance. Thus, in recent decades, several alternative, nonantibiotic approaches have been evaluated.

SUMMARY

There is a critical need for a concerted and standardized methodology for diagnosing, treating, and monitoring women with rUTIs. Additionally, novel nonantibiotic alternative treatment and preventive measures for UTIs are desperately required to address the global issue of antibiotic recalcitrance in all age groups, and specifically older women. Research efforts have sought to develop alternative and more effective techniques; many of which appear to be promising, but require additional evaluation and validation through clinical trials.

Prescribing Trend of Antibiotics Among the Patients Admitted in Intensive Medical Care Unit: A Prospective Observational Study

BACKGROUND

Intensive medical care units (IMCUs) usually admit patients who are in critical medical need and require the utmost attention of healthcare professionals, along with the best treatment options available. These patients are prone to infections and require various antibiotics for the treatment. Varying costs of antibiotics, variable dosage forms, and antibiotic resistance cause an economic burden on patients Methodology: This study was designed and conducted prospectively to evaluate the prescribing pattern of antibiotics at the IMCU in a tertiary care hospital. A total of 102 patients were included in the study based on the exclusion and inclusion criteria, and the collected data was tabulated in an Excel sheet and analyzed using Prism GraphPad software. Data were presented as numbers and percentages.

RESULTS

Most of the patients were in the age group of 41-50 years. The number of male patients was slightly more than that of female patients. The majority of the patients admitted to the IMCU had acute pulmonary edema and cerebrovascular accidents. Most antibiotics were prescribed empirically and administered parenterally, of which Amoxicillin + Potassium clavulanate was the most commonly used antibiotic. Tigecycline had the highest daily defined dose per 100 bed days value, and injection Sulbactam + Cefoperazone was the costliest of all antibiotic therapy.

CONCLUSION

Antibiotic therapy used in the IMCU consisting of Sulbactam + Cefoperazone was found to be costlier, and Amoxicillin + Potassium clavulanate were the commonly prescribed antibiotics among the other prescribed antibiotics. The average cost of antibiotics was found to be higher, which increased the economic healthcare burden for patients and their families.

The impact of Boric Acid tubes on quantitative urinary bacterial cultures in hospitalized patients

INTRODUCTION

The accuracy of urine culture results can be affected by pre-analytical factors such as transport delays and storage conditions. The objectives of this study were to analyze urine collection practices and assess the impact of introducing boric acid tubes for urine collection on quantitative urinary bacterial cultures of hospitalized patients in medical wards.

METHODS

A quasi-experimental pre-post study conducted in an acute care facility. In the pre-intervention phase (2020-2021), urine samples were transported without preservatives at room temperature. In 2022 (post-intervention), we transitioned to boric acid transport tubes, evaluating its effect on significant bacterial growth (≥ 105 CFU/ml). Bivariate and multivariate analyses identified predictors of culture positivity.

RESULTS

Throughout the duration of the study, a total of 12,660 urine cultures were analyzed. Date and time documentation was complete for 38.3% of specimens. Culture positivity was higher with longer processing times: positivity was 21.3% (220/1034) when specimens were processed within 4 h, 28.4% (955/3364) when processed in 4-24 h, and 32.9% (137/417) when processed after 24 h (p < 0.0001). For 4-24-hour processing, positivity decreased from 30.4% (704/2317) pre-intervention to 24.0% (251/1047) post-intervention (p < 0.001), with no significant changes in < 4 or ≥ 24-hour specimens. Stratified analysis by processing time revealed that the intervention was associated with reduced positivity only in cultures processed within 4-24 h (OR 0.80, 95% CI 0.67-0.94; p = 0.008).

CONCLUSION

The introduction of boric acid transport tubes predominantly influenced cultures transported within a 4-24-hour window. This presents an opportunity to improve urine tract infection diagnostic practices in healthcare settings.

Follow-up of patients with urinary tract infections discharged from the emergency department: a mixed methods study

OBJECTIVES

To evaluate the quality of culture follow-up after emergency department (ED) discharge in patients with urinary tract infections (UTIs).

METHODS

This convergent mixed methods study included an observational cohort study and a qualitative interview study in UTI patients discharged from the ED of a Dutch university hospital. The primary outcomes of the observational study were the proportion of patients requiring adjustment of antibiotic therapy after culture review, and the proportion of patients in whom these adjustments were made. Logistic regression identified factors associated with these outcomes. Interviews assessed patient experiences and transcripts were analysed using inductive thematic content analysis. Integration of the results informed recommendations for high-quality follow-up.

RESULTS

Out of 455 patients, 285 (63%) required culture-based treatment adjustments. In most patients, no adjustments were made (239/285, 84%). De-escalation was most frequently omitted (98%), followed by discontinuation of antibiotics (92%). A mean of 7.1 (SD  3.8) antibiotic days per patient could have been avoided in 103 patients. Patients with diabetes were less likely to require adjustments (aOR   0.50, 95%-CI  0.29-0.85). Patients with moderate or severe renal impairment (aOR  4.1, 95%-CI  1.45-11.33; aOR  4.2, 95%-CI   1.50-11.94) or recurrent UTIs (aOR  5.0, 95%-CI  2.27-11.18) were more likely to have received necessary adjustments. Twelve interviews also revealed varying degrees of follow-up. Three themes were identified: 'information and communication', 'coordination and accessibility of care' and 'individual needs and preferences'. Recommendations for high-quality follow-up advocate a person centred approach.

CONCLUSIONS

This study highlights the importance of urine culture follow-up after ED discharge, mainly to reduce unnecessary antibiotic treatment, promote de-escalation and improve patient experience.

The Impact of Polymerase Chain Reaction Urine Testing on Clinical Decision-Making in the Management of Complex Urinary Tract Infections

While urinary polymerase chain reaction (PCR) testing is effective in organism identification in patients with complex urinary tract infections (cUTI), limited data exists on the clinical usefulness of this test. We serially surveyed physicians treating symptomatic patients with cUTI both at presentation and after PCR, and urine culture (UC) results were available to ascertain how the test results modified the therapy. A total of 96 unique surveys completed by 21 providers were included in the data analysis. The mean age for female and male patients was 69.4 ± 15.5 and 71.6 ± 12.7 years, respectively. The test positivity and line-item concordance for UC and PCR were consistent with prior reports. The PCR results modified or confirmed treatment in 59/96 (61.5%) and 25/96 (26.0%) of the cases, respectively, with 12/29 (41.4%) and 47/67 (70.1%) having negative and positive PCR results, respectively, resulting in treatment change (difference 28.7%, p < 0.01). Of these, 55/59 (57.3%) were alterations in the antibiotic regimen. PCR use to modify treatment was similar across providers and not statistically different when stratified by patient age, gender, or prior empiric therapy. In 31/59 (52.5%) of the cases, the PCR results modified the treatment where UC would not; conversely, UC would have modified the treatment in 3/37 (8.1%) of the cases where PCR did not (difference 44.4%, p < 0.01). We find that PCR test results are used by clinicians in managing cUTI, and use of this test provides an opportunity to improve antibiotic stewardship in this difficult-to-treat subset of patients.

Case report: Long-term follow-up of patients who received a FimCH vaccine for prevention of recurrent urinary tract infections caused by antibiotic resistant Enterobacteriaceae: a case report series

Urinary tract infections (UTI) caused by carbapenem-resistant Enterobacteriaceae (CRE) are considered one of the most urgent health threats to humans according to the Centers for Disease Control (CDC), and the World Health Organization (WHO). A FimCH Vaccine expanded access study is being conducted in patients with a history of antibiotic resistant UTIs who are considered to be at risk for development of CRE UTI. This case series describes the clinical, safety and immunogenicity findings for four participants who received a FimCH four-vaccine series. Participants were followed for 12 months after administration of the fourth vaccine for safety, general health status and UTI occurrence. The study was later amended to allow additional follow-up of up to five years post vaccine administration to assess long-term health status, UTI occurrences and to obtain blood samples for anti-FimH antibody testing. In our population of 4 study participants, the number of symptomatic UTI occurrences caused by gram-negative bacteria in the 12-month period following peak anti-FimH antibody response were approximately 75% lower than the 12-month period preceding study enrollment. These results are consistent with the 30-patient cohort of a Phase 1 study with the same FimCH Vaccine. UTI occurrences increased during the long-term follow-up period for all 4 participants but did not reach the rate observed pre-vaccination. No new safety concerns related to the FimCH Vaccine were identified during long-term follow-up. This case series has clinical importance and public health relevance since it examines and reports on UTI frequency and recurrence following vaccination with the FimCH Vaccine in a high-risk population of patients with recurrent UTI. Additionally, participants described improved well-being following vaccination which was maintained in the long-term follow-up period.

Potential of an Isolated Bacteriophage to Inactivate Klebsiella pneumoniae: Preliminary Studies to Control Urinary Tract Infections

Urinary tract infections (UTIs) caused by resistant Klebsiella pneumoniae can lead to severe clinical complications and even death. An alternative treatment option for infected patients is using bacteriophages. In the present study, we isolated phage VB_KPM_KP1LMA (KP1LMA) from sewage water using a K. pneumoniae strain as a host. Whole-genome analysis indicated that the genome was a double-stranded linear 176,096-bp long DNA molecule with 41.8% GC content and did not contain virulence or antibiotic resistance genes. The inactivation potential of phage KP1LMA was assessed in broth at an MOI of 1 and 10, and a maximum inactivation of 4.9 and 5.4 log CFU/mL, respectively, was observed after 9 h. The efficacy at an MOI of 10 was also assessed in urine to evaluate the phage's performance in an acidic environment. A maximum inactivation of 3.8 log CFU/mL was observed after 9 h. The results suggest that phage KP1LMA could potentially control a UTI caused by this strain of K. pneumoniae, indicating that the same procedure can be used to control UTIs caused by other strains if new specific phages are isolated. Although phage KP1LMA has a narrow host range, in the future, efforts can be made to expand its spectrum of activity and also to combine this phage with others, potentially enabling its use against other K. pneumoniae strains involved in UTIs.

Significant Publications on Infectious Diseases Pharmacotherapy in 2021

Purpose: To summarize the most noteworthy infectious diseases (ID) pharmacotherapy articles published in peer-reviewed literature in 2021. Summary: Members of the Houston Infectious Diseases Network (HIDN) nominated articles that were deemed to have significant contributions to ID pharmacotherapy in 2021. These nominations included articles pertaining to both general ID, including coronavirus disease 2019 (COVID-19), and human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) pharmacotherapy. A total of 35 articles were nominated by HIDN: 30 articles pertaining to general ID pharmacotherapy and 5 articles with HIV/AIDS focus. To select the most influential articles of 2021, a survey was created and distributed to members of the Society of Infectious Diseases Pharmacists (SIDP). Of the 239 SIDP members who responded to the survey, there were 192 recorded votes for the top 10 general ID pharmacotherapy articles and 47 recorded votes for the top HIV/AIDS article, respectively. The top publications are summarized. Conclusion: Antimicrobial stewardship and the optimal management of infectious disease states continues to be a priority in the midst of the ongoing coronavirus disease 2019 (COVID-19) global pandemic. In light of the sheer volume of ID-related articles published in the past year, this review aims to aid clinicians in remaining up-to-date on key practice-changing ID pharmacotherapy publications from 2021.

Flow cytometric detection of vancomycin-resistant Enterococcus faecium in urine using fluorescently labelled enterocin K1

A urinary tract infection (UTI) occurs when bacteria enter and multiply in the urinary system. The infection is most often caused by enteric bacteria that normally live in the gut, which include Enterococcus faecium. Without antibiotic treatment, UTIs can progress to life-threatening septic shock. Early diagnosis and identification of the pathogen will reduce antibiotic use and improve patient outcomes. In this work, we develop and optimize a cost-effective and rapid (< 40 min) method for detecting E. faecium in urine. The method uses a fluorescently labelled bacteriocin enterocin K1 (FITC-EntK1) that binds specifically to E. faecium and is then detected using a conventional flow cytometer. Using this detection assay, urine containing E. faecium was identified by an increase in the fluorescent signals by 25-73-fold (median fluorescence intensity) compared to control samples containing Escherichia coli or Staphylococcus aureus. The method presented in this work is a proof of concept showing the potential of bacteriocins to act as specific probes for the detection of specific bacteria, such as pathogens, in biological samples.

Dominance of Escherichia coli sequence types ST73, ST95, ST127 and ST131 in Australian urine isolates: a genomic analysis of antimicrobial resistance and virulence linked to F plasmids

Extraintestinal pathogenic Escherichia coli (ExPEC) are the most frequent cause of urinary tract infections (UTIs) globally. Most studies of clinical E. coli isolates are selected based on their antimicrobial resistance (AMR) phenotypes; however, this selection bias may not provide an accurate portrayal of which sequence types (STs) cause the most disease. Here, whole genome sequencing (WGS) was performed on 320 E. coli isolates from urine samples sourced from a regional hospital in Australia in 2006. Most isolates (91%) were sourced from patients with UTIs and were not selected based on any AMR phenotypes. No significant differences were observed in AMR and virulence genes profiles across age sex, and uro-clinical syndromes. While 88 STs were identified, ST73, ST95, ST127 and ST131 dominated. F virulence plasmids carrying senB-cjrABC (126/231; 55%) virulence genes were a feature of this collection. These senB-cjrABC+ plasmids were split into two categories: pUTI89-like (F29:A-:B10 and/or >95 % identity to pUTI89) (n=73) and non-pUTI89-like (n=53). Compared to all other plasmid replicons, isolates with pUTI89-like plasmids carried fewer antibiotic resistance genes (ARGs), whilst isolates with senB-cjrABC+/non-pUTI89 plasmids had a significantly higher load of ARGs and class 1 integrons. F plasmids were not detected in 89 genomes, predominantly ST73. Our phylogenomic analyses identified closely related isolates from the same patient associated with different pathologies and evidence of strain-sharing events involving isolates sourced from companion and wild animals.

Empiric versus culture-based antibiotic therapy for UTIs in menopausal women

PURPOSE

To assess the benefits and risks associated with empiric prescription of antibiotic therapy for treatment of a urinary tract infection (UTI).

METHODS

Following IRB approval menopausal women presenting with a symptomatic UTI to a single urology clinic were prospectively assigned to one of the two treatment groups based on day of presentation: culture-based treatment (CB) (Monday, Tuesday, Wednesday) or empiric treatment (ET) (Thursday, Friday) and started on nitrofurantoin (NF) pending culture results. Both groups were contacted at 7 and 14 days following treatment. Side effects and answers to a standardized questionnaire (UTISA) were recorded. Success was defined as a total UTISA score < 3. Any NF retreatment, use of another antibiotic therapy, or extension of the original antibiotic course was considered treatment failures.

RESULTS

From July 2020 to March 2022, 65 women with 80 UTI events were included in the study, with CB treatment used for 60 UTIs and ET used for 23 UTIs. At 7 days after start of treatment, questionnaire failure rate was 44% (20/45) for the CB group and 16% (3/19) for the ET group (P = 0.076). At 14 days following start of treatment, questionnaire failure rate was 31% (13/42) for the CB group and 17% (3/18) for the ET group (P = 0.3). In the ET group, 11% of cultures were found to be resistant to NF.

CONCLUSION

Outcomes for the empiric treatment of uncomplicated UTI with NF at both 7 and 14 days are not significantly different than outcomes with culture-based treatment.

Implementation of antimicrobial stewardship programmes in private healthcare settings in Africa: A scoping review

Background

An Antimicrobial Stewardship Programme (ASP) is one of the strategic objectives of the World Health Organization's (WHO) global action plan to combat antimicrobial resistance. There have been numerous publications on the implementation of ASPs in both private and public sectors globally. However, there are no reviews and interpretive scholarly research publications on successful implementation of ASPs in private healthcare settings in Africa.

Aim

The aim of this study was to systematically gather relevant information from published findings and to interpret those findings into a coherent body of lessons learnt from successful ASP implemented in private healthcare settings in Africa.

Method

Google Scholar and PubMed, which are online databases, were extensively searched, and studies, which met the inclusion criteria for this review, were retrieved. A data-charting list was developed to extract relevant data.

Results

Only six South African studies reported on successful implementation of ASPs in private healthcare settings in Africa. The main focus areas include locally driven prescription audits as well as pharmacist-led interventions.

Conclusion

Although private healthcare settings in Africa utilise antibiotic therapy for various infectious diseases, reports on implementation of ASPs in these settings are limited. To win the battle against antimicrobial resistance, private healthcare settings in Africa need to implement evidence-based guidelines and report on the rational use of antibiotics.

Contribution

The private healthcare sector in Africa needs to play a more meaningful role in the implementation of ASPs.

A Matrix-Assisted Laser Desorption Ionization-Time of Flight Mass Spectrometry Direct-from-Urine-Specimen Diagnostic for Gram-Negative Pathogens

Urinary tract infections (UTIs) pose a major public health burden. The vast majority of UTIs are caused by Gram-negative bacteria. Current culture-based pathogen identification methods may require up to 24 to 48 h of incubation. In this study, we developed and evaluated a method for Gram-negative pathogen identification direct from urine, without culture, via matrix-assisted laser desorption ionization-time of flight mass spectrometry (MALDI-TOF MS) in approximately 1 h. Urine samples were collected (n = 137) from the University of Maryland Medical Center clinical microbiology laboratory. To identify bacteria direct from urine, two methods were evaluated. First, 1 μL of urine was directly spotted onto the MALDI target plate, and second, 1 mL of urine was centrifuged at 8,000 rpm for 5 min before processing using the fast lipid analysis technique (FLAT). Mass spectra were acquired on the Bruker MALDI Biotyper sirius system in the negative-ion mode. Results were compared to those of standard culture methods. When 1 μL of urine was directly spotted, positive agreement was 81.5% (101/124) and, after centrifugation, 94.4% (117/124) relative to that of standard culture methods. Negative agreement for both methods was 100% (13/13). The time to results for both of the specimen preparation methods using the FLAT extraction protocol was approximately 1 h, with minimal hands-on time required (<5 min). The ability to rapidly identify pathogens directly from urine, without the need for culture, allows for faster turnaround times and, potentially, improved patient outcomes. Overall, the FLAT extraction protocol, in combination with lipid A identification, provides a reproducible and accurate method to rapidly identify urinary pathogens. IMPORTANCE This study describes and evaluates a direct-from-urine extraction method that allows identification of Gram-negative bacteria via MALDI-TOF MS within 1 h. Currently, identification of urinary pathogens requires 24 h of culture prior to identification. While this method may not replace culture, we demonstrate its utility in screening for common urinary pathogens. By providing identifications in under 1 h, clinicians can potentially treat patients sooner with more-targeted antimicrobial therapy. In turn, earlier treatment can improve patient outcome and antimicrobial stewardship. Furthermore, MADLI-TOF MS is a readily available, easy-to-use diagnostic tool in clinical laboratories, making implementation of this method possible.

A Baker's Dozen of Top Antimicrobial Stewardship Intervention Publications in Non-Hospital Care Settings in 2021

The scope of antimicrobial stewardship programs has expanded beyond the acute hospital setting. The need to optimize antimicrobial use in emergency departments, urgent, primary, and specialty care clinics, nursing homes, and long-term care facilities prompted the development of core elements of stewardship programs in these settings. Identifying the most innovative and well-designed stewardship literature in these novel stewardship areas can be challenging. The Southeastern Research Group Endeavor (SERGE-45) network evaluated antimicrobial stewardship-related, peer-reviewed literature published in 2021 that detailed actionable interventions specific to the nonhospital setting. The top 13 publications were summarized following identification using a modified Delphi technique. This article highlights the selected interventions and may serve as a key resource for expansion of antimicrobial stewardship programs beyond the acute hospital setting.

Recurrent urinary tract infection and estrogen shape the taxonomic ecology and function of the postmenopausal urogenital microbiome

Postmenopausal women are severely affected by recurrent urinary tract infection (rUTI). The urogenital microbiome is a key component of the urinary environment. However, changes in the urogenital microbiome underlying rUTI susceptibility are unknown. Here, we perform shotgun metagenomics and advanced culture on urine from a controlled cohort of postmenopausal women to identify urogenital microbiome compositional and function changes linked to rUTI susceptibility. We identify candidate taxonomic biomarkers of rUTI susceptibility in postmenopausal women and an enrichment of lactobacilli in postmenopausal women taking estrogen hormone therapy. We find robust correlations between Bifidobacterium and Lactobacillus and urinary estrogens in women without urinary tract infection (UTI) history. Functional analyses reveal distinct metabolic and antimicrobial resistance gene (ARG) signatures associated with rUTI. Importantly, we find that ARGs are enriched in the urogenital microbiomes of women with rUTI history independent of current UTI status. Our data suggest that rUTI and estrogen shape the urogenital microbiome in postmenopausal women.

In Vitro Activity of Tebipenem against Various Resistant Subsets of Escherichia coli Causing Urinary Tract Infections in the United States (2018 to 2020)

This study investigated the activity of an oral carbapenem, tebipenem, against various molecularly characterized subsets of Escherichia coli. A total of 15.0% of E. coli isolates (360/2,035 isolates) met the MIC criteria for screening for β-lactamases. Most of those isolates (74.7% [269/360 isolates]) carried bla_CTX-M. The CTX-M distribution varied (50% to 86%) among Census Regions, as did that of plasmid AmpC genes (up to 41% among E. coli isolates from the New England Region). Tebipenem and intravenous carbapenems showed uniform activity against various E. coli subsets.

Systematic review of the effect of D‑mannose with or without other drugs in the treatment of symptoms of urinary tract infections/cystitis (Review)

Several studies, reviews and meta-analyses have documented that D-mannose use lowers the risk of recurrent urinary tract infections (UTI), but its role in the treatment of UTI/cystitis-related symptoms is unclear. In particular, no systematic review has analyzed the role of treatment with D-mannose in acute UTI/cystitis. In this paper, we systematically reviewed the published data on the effect of D-mannose, alone or in association with other compounds, on the typical symptoms of UTI/cystitis. PubMed/Medline and EMBASE databases were searched, from 1990 to January 2022, using combinations of the following keywords: ‘urinary tract infections’, ‘cystalgia’, ‘recurrent next urinary tract infection’, ‘cystitis’, ‘mannose’, ‘mannoside’, ‘D-mannose’, ‘bacteriuria’, ‘pyuria’, ‘pyelocystitis’ with the appropriate Boolean modifiers (Limits: Human, English, full article). Studies were selected for the systematic review if they were clinical studies and reported original data, the number of patients using D-mannose alone or in association with other treatments, and the number of patients with symptoms of UTI/cystitis at trial entry and after the follow-up period. A total of seven studies were identified. D-mannose was given alone in two studies, and was associated with cranberry extract, Morinda citrifolia fruit extract, pomegranate extract, fructo-oligosaccharides, lactobacilli, and N-acetylcysteine in the others. All studies reported that symptoms decreased after treatment with D-mannose. Despite the limitations of the studies, the consistent results observed among all studies give support to the general findings that D-mannose may be useful in the treatment of UTI/cystitis symptoms.

Comprehensive assessment of holding urine as a behavioral risk factor for UTI in women and reasons for delayed voiding

BACKGROUND

Women of reproductive age group have greater predilection to urinary tract infections (UTI). Various risk factors increase the prevalence in women. Emergence of multidrug resistant uropathogens make clinical management of UTI challenging. Here we assess holding of urine as risk factor of UTI in women and reasons for delayed voiding. We also investigate the relationship between frequency of UTIs and overall behavioural features, menstrual hygiene and attitude of women towards their own health issues.

METHODS

A questionnaire based cross-sectional study was performed with 816 hostel residents with written consent. Self-reported data was statistically analysed using SPSS software. Urinalysis and urine culture were done for 50 women by random sampling to obtain the information on leading causative agents of UTI in the study population and their antimicrobial resistance profile.

RESULTS

The prevalence of UTI among the participants without risk factors was found to be 27.5 (95% CI: 24.4-30.7). Attitude of women towards their own personal health issues and use of public toilets showed a correlation with prevalence of infection. Delay in urination on habitual basis was found to be associated with UTI. Uropathogens isolated by random sampling were resistant to multiple drugs that are generally used to treat UTI.

CONCLUSIONS

Holding urine for long time had proven to be an important risk factor and amongst different reasons of holding urine, holding due to poor sanitary condition of public toilets was the most common. Higher frequency of self-reported UTIs is related to holding of urine, behavioural features and attitude of women.

Combined Training Intervention Targeting Medical and Nursing Staff Reduces Ciprofloxacin Use and Events of Urinary Tract Infection

Inappropriate diagnosis of urinary tract infections (UTI) contributes to antimicrobial overuse. A combined training intervention for medical and nursing staff mainly addressing the analytic process reduced UTI events (9.20 vs. 7.36 per 1000 PD, −20.0%, p = 0.003) and the utilization rate of ciprofloxacin (11.6 vs. 3.5, −69.6 p = 0.001) in a Bavarian University Hospital. Combined training intervention—as part of an antibiotic stewardship program—can be effective in avoiding unnecessary urinalysis and reducing antibiotic consumption.

Impact of Education and Data Feedback on Guideline-Concordant Prescribing for Urinary Tract Infections in the Outpatient Setting

Background

Urinary tract infections (UTIs) are the most common outpatient indication for antibiotics and an important target for antimicrobial stewardship (AS) activities. With The Joint Commission standards now requiring outpatient AS, data supporting effective strategies are needed.

Methods

We conducted a 2-phase, prospective, quasi-experimental study to estimate the effect of an outpatient AS intervention on guideline-concordant antibiotic prescribing in a primary care (PC) clinic and an urgent care (UC) clinic between August 2017 and July 2019. Phase 1 of the intervention included the development of clinic-specific antibiograms and UTI diagnosis and treatment guidelines, presented during educational sessions with clinic providers. Phase 2, consisting of routine clinic- and provider-specific feedback, began ~12 months after the initial education. The primary outcome was percentage of encounters with first- or second-line antibiotics prescribed according to clinic-specific guidelines and was assessed using an interrupted time series approach.

Results

Data were collected on 4724 distinct patients seen during 6318 UTI encounters. The percentage of guideline-concordant prescribing increased by 22% (95% CI, 12% to 32%) after Phase 1 education, but decreased by 0.5% every 2 weeks afterwards (95% CI, –0.9% to 0%). Following routine data feedback in Phase 2, guideline concordance stabilized, and significant further decline was not seen (–0.6%; 95% CI, –1.6% to 0.4%). This shift in prescribing patterns resulted in a 52% decrease in fluoroquinolone use.

Conclusions

Clinicians increased guideline-concordant prescribing, reduced UTI diagnoses, and limited use of high-collateral damage agents following this outpatient AS intervention. Routine data feedback was effective to maintain the response to the initial education.

The Five Ds of Outpatient Antibiotic Stewardship for Urinary Tract Infections

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.

The Path of More Resistance: A Comparison of NHSN and CLSI Criteria in Developing Cumulative Antimicrobial Susceptibility Test Reports and Institutional Antibiograms

Background In the absence of antimicrobial susceptibility data, the institutional antibiogram is a valuable tool to guide clinicians in the empiric treatment of infections. However, there is a misunderstanding on how best to prepare cumulative antimicrobial susceptibility testing reports (CASTRs) to guide empiric therapy (e.g., routine antibiogram) versus monitoring antimicrobial resistance, with the former following guidance from the Clinical Laboratory Standards Institute (CLSI), and the latter from Center for Disease Control and Preventions National Healthcare Safety Network (NHSN). These criteria vary markedly in their exclusion or inclusion of isolates cultured repeatedly from the same patient. Methods We compared rates of non-susceptibility (NS)using annual data from a large teaching healthcare system subset to isolates eligible by either NHSN criteria or CLSI criteria. Results For a panel of the three most prevalent gram-negative pathogens in combination with clinically relevant antimicrobial agents (or priority pathogen-agent combinations, PPACs), we found that the inclusion of duplicate isolates by NHSN criteria yielded higher NS rates than when CLSI criteria (for which duplicate isolates are not included) were applied. Conclusions Patients with duplicate isolates may not be representative of antimicrobial resistance within a population. For this reason, users of CASTR data should carefully consider that the criteria used to generate these reports can impact resulting NS rates, and therefore maintain the distinction between CASTRs created for different purposes.

Interplay between Phenotypic Resistance to Relevant Antibiotics in Gram-Negative Urinary Pathogens: A Data-Driven Analysis of 10 Years' Worth of Antibiogram Data

The global emergence of antimicrobial resistance (AMR) has become a critical issue for clinicians, as it puts the decades of developments in the medical field in jeopardy, by severely limiting the useful therapeutic arsenal of drugs, both in nosocomial and community-acquired infections. In the present study, a secondary analysis of taxonomic and resistance data was performed, corresponding to urinary tract infections (UTIs) caused by Gram-negative bacteria, detected between 1 January 2008 to 31 December 2017 at the Albert Szent-Györgyi Health Center, University of Szeged. The following were identifiable from the data collected: year of isolation; outpatient (OP)/inpatient (IP) origin of the isolate; taxonomy; and susceptibility/resistance to selected indicator antibiotics. Principal component analysis (PCA) and a correlation matrix were used to determine the association between the presences of resistance against indicator antibiotics in each taxonomic group. Overall, data from n = 16,240 outpatient and n = 13,964 inpatient Gram-negative UTI isolates were included in the data analyses. In E. coli, strong positive correlations were seen between resistance to ciprofloxacin (CIP) and gentamicin (GEN) resistance (OP: r = 0.6342, p = 0.049; IP: r = 0.9602, p < 0.001), whereas strong negative correlations were shown for fosfomycin (FOS) and nitrofurantoin (NIT) resistance (OP: r = -0.7183, p = 0.019; IP: r = -0.7437; p = 0.014). For Klebsiella spp. isolates, CIP resistance showed strong positive correlation with resistance to third-generation cephalosporins (3GC) and GEN (r = 0.7976, p = 0.006 and r = 0.7428, p = 0.014, respectively) in OP isolates, and with resistance to trimethoprim-sulfamethoxazole (SXT) and FOS (r = 0.8144, p = 0.004 and r = 0.7758, p < 0.001, respectively) in IP isolates. For members of the Citrobacter-Enterobacter-Serratia group, the resistance among indicator antibiotics showed a strong positive correlation, with the exception of FOS resistance. In the Proteus-Providencia-Morganella group, the strongest association was noted between CIP and SXT resistance (OP: r = 0.9251, p < 0.001; IP: r = 0.8007; p = 0.005). In the case of OP Acinetobacter spp., CIP showed strong and significant positive correlations with most indicator antibiotics, whereas for IP isolates, strong negative correlations arose among imipenem (IMI) resistance and resistance to other drugs. For Pseudomonas spp., strong and positive correlations were noted among resistance to β-lactam antibiotics and aminoglycosides, with the exception of ceftazidime (CEFT), showing strong, but negative correlations. Though molecular tests and sequencing-based platforms are now considered as the gold-standard for AMR surveillance, standardized collection of phenotypic resistance data and the introduction of Big Data analytic methods may be a viable alternative for molecular surveillance, especially in low-resource settings.

Urinary Tract Infections in Elderly Patients: A 10-Year Study on Their Epidemiology and Antibiotic Resistance Based on the WHO Access, Watch, Reserve (AWaRe) Classification

The ageing of the population-especially in developed countries-has brought on many societal challenges and has significantly contributed to the burden on healthcare infrastructures worldwide. Elderly persons (aged ≥ 65 years) are at higher risk for developing UTIs, due to a range of intrinsic and extrinsic risk factors, and they often delay seeking treatment. A retrospective observational study was performed regarding the epidemiology and resistance of UTIs in elderly patients. Identification of the isolates was carried out using VITEK 2 ID/AST and MALDI-TOF mass spectrometry. Antibiotic resistance in these isolates was assessed based on EUCAST guidelines, and were grouped into the WHO AWaRe (Access, Watch, Reserve) classification of antimicrobials. During the 10-year study period, n = 4214 (421.4 ± 118.7/year) and n = 4952 (495.2 ± 274.6) laboratory-confirmed UTIs were recorded in inpatients and outpatients, respectively. The causative agents showed differentiation among outpatients and inpatients: Escherichia coli (48.14% vs. 25.65%; p = 0.001), Enterococcus spp. (20.15% vs. 21.52%; p > 0.05), Klebsiella spp. (16.28% vs. 16.26%; p > 0.05), Pseudomonas spp. (4.40%vs. 13.36%; p = 0.001); Proteus-Providencia-Morganella group (4.56% vs. 10.96%; p = 0.001); Candida spp. (0.53% vs. 5.98%; p = 0.001); Citrobacter-Enterobacter-Serratia group (1.90% vs. 2.71%; p < 0.05). Significantly higher resistance rates were observed in inpatient isolates for many Access and Watch antibiotics compared to isolates of outpatient origin; in addition, resistance rates were higher in these uropathogens compared to the previously recorded rates in the region. More care should be taken for the diagnosis and treatment of UTIs affecting elderly patients, as they represent a particularly vulnerable patient population.

Fosfomycin susceptibility of uropathogens at Charlotte Maxeke Johannesburg Academic Hospital

Background

Multidrug-resistant uropathogens are becoming widespread both in community and hospital setting. Safe yet effective treatments are a priority. Fosfomycin is an antibacterial that displays good activity against most bacteria causing urinary tract infections (UTIs), including multidrug-resistant bacteria. The aim of this study was to evaluate fosfomycin susceptibility for uropathogens isolated from a microbiology laboratory at a tertiary academic hospital. In addition, this was compared to the susceptibility of other oral antimicrobials.

Methods

We conducted a retrospective analysis of laboratory reports for uropathogens isolated at Charlotte Maxeke Johannesburg Academic Hospital from September 2015 to August 2017. Antimicrobial susceptibility testing of the isolates was performed using the Kirby–Bauer disk diffusion method or the Vitek^® 2 system according to the Clinical and Laboratory Standards Institute.

Results

Overall susceptibility of fosfomycin for the 4700 Enterobacteriaceae isolates was 95.7%; 95% confidence interval (CI) 95.1–96.2. The overall susceptibility for fosfomycin against the gram-positives was 98.6%. There were 37.9% multidrug-resistant Enterobacteriaceae (MDRE) isolated during the study period. Fosfomycin displayed activity against 94.4% of extended-spectrum β-lactamase (ESBL) producers and 90.7% for carbapenem-resistant Enterobacteriaceae (CRE). None of the methicillin-resistant Staphylococcus aureus and vancomycin-resistant Enterococcus isolates tested was fosfomycin resistant. The overall in vitro susceptibility was significantly higher for fosfomycin (p = 0.0001) compared to amoxicillin/clavulanic acid, cephalexin, cefuroxime, ciprofloxacin, trimethoprim/sulfamethoxazole and nitrofurantoin.

Conclusion

This study confirmed the high susceptibility of fosfomycin against UTI pathogens isolated at our institution. In an era of increasing antimicrobial resistance, fosfomycin represents a potential option for the treatment of UTIs at Charlotte Maxeke Johannesburg Academic Hospital.

Antimicrobial Resistance Patterns of Urinary Escherichia coli Among Outpatients in Washington State, 2013-2017: Associations with Age and Sex

BACKGROUND

Management of acute, uncomplicated cystitis in outpatients benefits from knowledge of drug resistance patterns in the population. However, antibiograms are often not available for the outpatient setting, and the role of host factors such as sex and age in assessing the likelihood of resistance are not well understood. We investigated whether antibiotic resistance patterns of outpatient urinary Escherichia coli (EC) isolates vary by age group and sex in a large database of antibiotic susceptibility test (AST) results from Washington State.

METHODS

We retrospectively analyzed AST data for outpatient urinary EC isolates in Washington State tested at a clinical reference laboratory from 2013 - 2017. In logistic regression models stratified by sex, we tested the associations of antibiotic resistance with patient age.

RESULTS

We found females >50 years had greater odds than females younger than 19 for resistance to amoxicillin-clavulanate (odds ratio [OR], 1.43; 95% CI, 1.22-1.69), ciprofloxacin (OR, 3.04; 95% CI, 2.48-3.74), ceftriaxone (OR, 2.58; 95% CI, 1.77-3.92), and gentamicin (OR, 1.62; 95% CI, 1.27-2.08) (all p<0.001). Compared to males younger than 19, males >50 years had greater odds of resistance to ciprofloxacin (OR, 2.59; 95% CI, 1.18-5.69) and lower odds of resistance to amoxicillin-clavulanate (OR, 0.56; 95% CI, 0.34-0.96) (all p<0.05).

CONCLUSION

These findings demonstrate that age and sex are associated with variability in antibiotic resistance patterns in the outpatient setting. Availability of outpatient antibiotic resistance data based on sex and age may be useful to inform empiric prescribing for outpatient UTIs and to support antibiotic stewardship efforts.

Antibiotic Prescription Practice for Pediatric Urinary Tract Infection in a Tertiary Center

OBJECTIVES

Prescribing antibiotics for suspected urinary tract infection (UTI) is common practice and may lead to unnecessary antibiotic exposure. We aimed to review UTI diagnosis and management in the emergency department and to identify targets for antimicrobial stewardship.

METHODS

Single-center, retrospective cohort study of children aged 12 weeks to younger than 18 years discharged from the emergency department with a diagnosis of UTI between October and December 2016. Children with genitourinary malformations were excluded. Clinical information, urine collection method, laboratory findings, and urine culture results were gathered. The sensitivity and specificity of nitrite and leukocyte esterase for UTI diagnosis were calculated. The relationship between urinalysis characteristics and confirmed UTI was examined using logistic regression.

RESULTS

A total of 183 children with a median (interquartile range) age of 4.2 (1.1-7.5) years were included; 82.5% were female. Almost all children were discharged home on antibiotics (n = 180, 98%) for a median (interquartile range) duration of 7 (7-10) days. A total of 85 patients (46.4%) received antibiotics despite negative urine cultures leading to 525 unnecessary antibiotic days. The presence of nitrites was the strongest predictor of UTI (odds ratio = 20.22, P < 0.001) and was highly specific.

CONCLUSIONS

Current practice in managing suspected pediatric UTIs in our ED resulted in significant and unnecessary antibiotic exposure. We identified targets to reduce unnecessary antibiotic exposure including improving the diagnostic accuracy of UTIs, a process to discontinue antibiotics for negative cultures and standardizing antimicrobial duration.

Anti-Biofilm Effect of Octenidine and Polyhexanide on Uropathogenic Biofilm-Producing Bacteria

BACKGROUND

A catheter allowing a release of antibacterial substances such as antiseptics into the bladder could be a new way of preventing biofilm formation and subsequent catheter-associated urinary tract infections.

METHODS

Minimal inhibitory and bactericidal concentration (MIC/MBC) determinations in cation-adjusted Mueller-Hinton broth and artificial urine were performed for 4 antiseptics against 3 uropathogenic biofilm producers, Escherichia coli, Pseudomonas aeruginosa, and Proteus mirabilis. Furthermore, effects of octenidine and polyhexanide against catheter biofilm formation were determined by quantification of biofilm-producing bacteria.

RESULTS

Sodium hypochlorite showed MIC/MBC values between 200 and 800 mg/L for all strains tested. Triclosan was efficient against E. coli and P. mirabilis (MIC ≤2.98 mg/L) but ineffective against P. aeruginosa. Octenidine and polyhexanide showed antibacterial activity against all 3 species tested (MIC 1.95-7.8 and 3.9-31.25 mg/L). Both octenidine and polyhexanide were able to prevent biofilm formation on catheter segments in a concentration dependent manner. Furthermore, adding 250 mg/L of each biocide disrupted biofilms formed by E. coli and P. mirabilis, whereas even 500 mg/L was not sufficient to completely destroy P. aeruginosa biofilms.

CONCLUSION

Octenidine- and polyhexanide-containing antiseptics showed a broad effect against typical uropathogenic biofilm producers even in high dilutions. This study provides a basis for further investigation of the potential of octenidine and polyhexanide as prophylaxis or treatment of catheter biofilms.

The Role of Gram-Negative Bacteria in Urinary Tract Infections: Current Concepts and Therapeutic Options

Urinary tract infections (UTIs) are some of the most common infections in human medicine worldwide, recognized as an important public health concern to healthcare systems around the globe. In addition, urine specimens are one of the most frequently submitted samples for culture to the clinical microbiology laboratory, exceeding the number of most of the other sample types. The epidemiology, species-distribution and susceptibility-patterns of uropathogens vary greatly in a geographical and time-dependent manner and it also strongly correlated with the reported patient population studied. Nevertheless, many studies highlight the fact that the etiological agents in UTIs have changed considerably, both in nosocomial and community settings, with a shift towards "less common" microorganisms having more pronounced roles. There is increasing demand for further research to advance diagnostics and treatment options, and to improve care of the patients. The aim of this review paper was to summarize current developments in the global burden of UTI, the diagnostic aspects of these infectious pathologies, the possible etiological agents and their virulence determinants (with a special focus on the members of the Enterobacterales order), current guidelines and quality indicators in the therapy of UTIs and the emergence of multidrug resistance in urinary pathogens.

Molecular determinants of disease severity in urinary tract infection

The most common and lethal bacterial pathogens have co-evolved with the host. Pathogens are the aggressors, and the host immune system is responsible for the defence. However, immune responses can also become destructive, and excessive innate immune activation is a major cause of infection-associated morbidity, exemplified by symptomatic urinary tract infections (UTIs), which are caused, in part, by excessive innate immune activation. Severe kidney infections (acute pyelonephritis) are a major cause of morbidity and mortality, and painful infections of the urinary bladder (acute cystitis) can become debilitating in susceptible patients. Disease severity is controlled at specific innate immune checkpoints, and a detailed understanding of their functions is crucial for strategies to counter microbial aggression with novel treatment and prevention measures. One approach is the use of bacterial molecules that reprogramme the innate immune system, accelerating or inhibiting disease processes. A very different outcome is asymptomatic bacteriuria, defined by low host immune responsiveness to bacteria with attenuated virulence. This observation provides the rationale for immunomodulation as a new therapeutic tool to deliberately modify host susceptibility, control the host response and avoid severe disease. The power of innate immunity as an arbitrator of health and disease is also highly relevant for emerging pathogens, including the current COVID-19 pandemic.

Etiological Agents of Urinary Tract Infection and 7 Years Trend of Antibiotic Resistance of Bacterial Uropathogens in Sudan

Introduction:

Bacterial infections of the urinary tract represent a major cause of outpatient visits as well as hospital-acquired infections. As the prevalence of multidrug-resistant uropathogens is increasing, updated knowledge of the commonest bacterial causes and their susceptibility patterns is crucial for the proper selection and use of antimicrobial drugs and the development of effective local prescribing guidelines.

Methods:

Handling of urine samples, identification of organisms and antimicrobial susceptibility testing were made according to guidelines in Monica Cheesbrough 2000, 2006. The prevalence of resistance of the pathogens against each antibiotic was calculated as the proportion of resistant isolates over the entire tested isolates. Data were analyzed using Epi info; the chi-square test and Fisher exact test were used to assess the statistical significance of results.

Results:

In this study, 774 samples were cultured from patients with suspected urinary tract infection (UTI), 705 (91%) urinary isolates showed significant growth (>105 CFU /L) while the other 69 samples showed no significant growth. 431 (61%) of the patients were female, while the other 274 (39%) were males. 13 types of pathogens were identified in 705 urinary isolates. E.Coli was the main bacterial uropathogen identified. Microbiological susceptibility of a total of 28 antibiotics was tested; for each urinary isolate, different sets of these antibiotics were used. 601(96%) of the bacteria were resistant to at least one antibiotic. 17 antibiotics were found to have a bacterial resistance rate of more than 50%, including all B lactams (except cefuroxime), Nalidixic acid, Ciprofloxacin, Norfloxacin, Clindamycin, Co-Trimoxazole and Tetracyclines(Tetracycline and Doxycycline). Other antibiotics were found to have resistance rates of less than 50%. Amikacin & Imipenem had the highest susceptibility rates. Throughout the 7 years, resistance to most of the antibiotics showed an incremental pattern.

Conclusion:

Current empirical antibiotic therapy for UTI should be modified, and new guidelines should be established based on local resistance rates. This study comes up with precious regional data for evidence-based empirical antibiotic treatment, but a national sentinel surveillance system and regional antibiograms should be established to track the bacterial susceptibility profiles in Sudan.

Safety and immunogenicity of an adjuvanted Escherichia coli adhesin vaccine in healthy women with and without histories of recurrent urinary tract infections: results from a first-in-human phase 1 study

Antibiotic resistance among gram-negative bacteria continues to rise globally at an alarming rate. New vaccines that prevent bacterial infections and reduce antibiotic use could provide a potential solution to these problems. This study focused on development of an investigational vaccine to prevent recurrent urinary traction infections (UTI) caused by gram-negative bacteria that use type 1 pili to adhere to, invade, and colonize human bladders. The vaccine antigen is FimH, an adhesin protein on the tip of type 1 pili with a lectin binding domain that enables attachment to glycoproteins on mammalian bladders. This was a phase 1, open-label, dose escalation study evaluating the vaccine in 67 healthy women with and without histories of recurrent UTI. The objectives of the study were to evaluate the safety, tolerability, and immunogenicity of different dosages of the antigen and adjuvant of the vaccine. All dosages were well-tolerated and a low incidence of systemic reactions occurred. No serious adverse events related to the vaccine were reported. The vaccine induced both binding and functional antibodies. The women with histories of recurrent UTI demonstrated greater than 150-fold increases in antibodies against the N-terminal region of FimH. Based on the results of this phase 1 study, this vaccine is proceeding to a double-blind, randomized, placebo-controlled phase 2 study. If this vaccine is successful in future studies, it could potentially prevent millions of recurrent UTI globally and reduce the development of antibiotic resistance.

Genomic analysis of trimethoprim-resistant extraintestinal pathogenic Escherichia coli and recurrent urinary tract infections

Urinary tract infections (UTIs) are the most common bacterial infections requiring medical attention and a leading justification for antibiotic prescription. Trimethoprim is prescribed empirically for uncomplicated cases. UTIs are primarily caused by extraintestinal pathogenic Escherichia coli (ExPEC) and ExPEC strains play a central role in disseminating antimicrobial-resistance genes worldwide. Here, we describe the whole-genome sequences of trimethoprim-resistant ExPEC and/or ExPEC from recurrent UTIs (67 in total) from patients attending a regional Australian hospital from 2006 to 2008. Twenty-three sequence types (STs) were observed, with ST131 predominating (28 %), then ST69 and ST73 (both 7 %). Co-occurrence of trimethoprim-resistance genes with genes conferring resistance to extended-spectrum β-lactams, heavy metals and quaternary ammonium ions was a feature of the ExPEC described here. Seven trimethoprim-resistance genes were identified, most commonly dfrA17 (38 %) and dfrA12 (18 %). An uncommon dfrB4 variant was also observed. Two blaCTX-M variants were identified - blaCTX-M-15 (16 %) and blaCTX-M-14 (10 %). The former was always associated with dfrA12, the latter with dfrA17, and all blaCTX-M genes co-occurred with chromate-resistance gene chrA. Eighteen class 1 integron structures were characterized, and chrA featured in eight structures; dfrA genes featured in seventeen. ST131 H30Rx isolates possessed distinct antimicrobial gene profiles comprising aac(3)-IIa, aac(6)-Ib-cr, aph(3')-Ia, aadA2, blaCTX-M-15, blaOXA-1 and dfrA12. The most common virulence-associated genes (VAGs) were fimH, fyuA, irp2 and sitA (all 91 %). Virulence profile clustering showed ST131 H30 isolates carried similar VAGs to ST73, ST405, ST550 and ST1193 isolates. The sole ST131 H27 isolate carried molecular predictors of enteroaggregative E. coli/ExPEC hybrid strains (aatA, aggR, fyuA). Seven isolates (10 %) carried VAGs suggesting ColV plasmid carriage. Finally, SNP analysis of serial UTI patients experiencing worsening sequelae demonstrated a high proportion of point mutations in virulence factors.

Increasing relevance of Gram-positive cocci in urinary tract infections: a 10-year analysis of their prevalence and resistance trends

Urinary tract infections (UTIs) are the third most common types of infection in human medicine worldwide. There is increasing appreciation for the pathogenic role of Gram-positive cocci (GPC) in UTIs, as they have a plethora of virulence factors, maintaining their pathogenicity and high affinity for the epithelial cells of the urinary tract. The study was carried out using microbiological data collected corresponding to the period between 2008 and 2017. Antimicrobial susceptibility testing was performed using the disk diffusion method and E-tests. The age range of patients affected from the outpatient and inpatient groups differed significantly (43 [range 0.7-99] vs. 68 [range 0.4-99] years; p = 0.008). 3962 GPCs were obtained from inpatient and 4358 from outpatient samples, corresponding to 20.5 ± 2.8% (range 17.5-26.8%) and 20.6 ± 2.6% (range 17.8-26.0%) of all positive urine samples (p > 0.05); in both groups, Enterococcus spp. were the most prevalent (outpatients: 79.6%; inpatients: 88.5%). High-level aminoglycoside resistance in enterococci was noted in 31.0-46.6% of cases. A pronounced increase in the number of MRSA was seen in the second half of the study period (0.6-1.9% vs. 9.8-11.6%; p = 0.038). The ratio of VRE isolates was 0.16%, no VISA/VRSA isolates were detected.

Increasing relevance of Gram-positive cocci in urinary tract infections: a 10-year analysis of their prevalence and resistance trends

Urinary tract infections (UTIs) are the third most common types of infection in human medicine worldwide. There is increasing appreciation for the pathogenic role of Gram-positive cocci (GPC) in UTIs, as they have a plethora of virulence factors, maintaining their pathogenicity and high affinity for the epithelial cells of the urinary tract. The study was carried out using microbiological data collected corresponding to the period between 2008 and 2017. Antimicrobial susceptibility testing was performed using the disk diffusion method and E-tests. The age range of patients affected from the outpatient and inpatient groups differed significantly (43 [range 0.7–99] vs. 68 [range 0.4–99] years; p = 0.008). 3962 GPCs were obtained from inpatient and 4358 from outpatient samples, corresponding to 20.5 ± 2.8% (range 17.5–26.8%) and 20.6 ± 2.6% (range 17.8–26.0%) of all positive urine samples (p > 0.05); in both groups, Enterococcus spp. were the most prevalent (outpatients: 79.6%; inpatients: 88.5%). High-level aminoglycoside resistance in enterococci was noted in 31.0–46.6% of cases. A pronounced increase in the number of MRSA was seen in the second half of the study period (0.6–1.9% vs. 9.8–11.6%; p = 0.038). The ratio of VRE isolates was 0.16%, no VISA/VRSA isolates were detected.

Epidemiology of antibiotic treatment for uncomplicated cystitis in adults in Japan

INTRODUCTION

A large number of antibiotics are used for the treatment of uncomplicated cystitis owing to its high morbidity. As the administration of antibiotics for uncomplicated cystitis may be considered an example of inappropriate use, outpatient antimicrobial stewardship for this condition is important. We evaluated the current pharmacoepidemiology trends for the treatment of uncomplicated cystitis in Japan to predict stewardship strategies.

METHODS

This descriptive observational study analyzed data from an anonymized claims database of employees and their family members covered by the employer's health insurance. We identified female outpatients diagnosed with acute cystitis (ICD-10 code N300) aged ≥15 years and extracted oral antibiotic prescription records between 2013 and 2016. We excluded prescriptions for >7 days.

RESULTS

The most prescribed antibiotic category was fluoroquinolones (52.67%), followed by cephalosporins and penems (40.63%). Third-generation cephalosporins accounted for 90.91% of cephalosporin and penem prescriptions. The most common duration of antibiotic prescription was 5 days, except for first-generation cephalosporins, penem (7 days) and sulfamethoxazole and trimethoprim (3 days).

CONCLUSION

Fluoroquinolones and third-generation cephalosporins were prescribed to most uncomplicated cystitis cases in Japan. Although the lack of alternatives to quinolones and beta-lactams in Japan is an obstacle for antimicrobial stewardship for uncomplicated cystitis, promoting accurate diagnoses and establishing alternatives available in the Japanese market are important. Shortening the treatment duration is also an important strategy. Further research is needed on local antimicrobial resistance patterns to determine a fixed treatment strategy for uncomplicated cystitis.

Antibiotic Prescribing in Primary Care for Urinary Tract Infections (UTIs) in Pregnancy: An Audit Study

Urinary tract infections (UTIs) are associated with negative pregnancy outcomes and are treated with antibiotics. Although beneficial, antibiotic use causes antimicrobial resistance (AMR), and therefore their use needs to be carefully balanced. Antimicrobial guidelines are developed to facilitate appropriate prescribing of antibiotics. This study assessed antibiotic prescribing for UTIs in pregnancy against the National Institute for Health and Care Excellence (NICE) guideline NG109. Fifty antibiotic prescribing records dated from 1st October 2018 to 1st July 2019 were identified from three London-based GP practices. The results show that a mid-stream sample of urine, which is important for the review and tailoring of antibiotic treatment, was collected in 77.6% of cases. Prescribing the first-line antibiotic is important for adequate treatment and good antimicrobial stewardship and results show that 44% of prescriptions were for the first-choice antibiotic. Most prescriptions (56%) were for a second-line or non-recommended antibiotic. Providing self-care advice is key to empowering pregnant women in managing their own health but only 16% of records documented provision of self-care advice. This study highlights important areas of concern in the management of UTIs in pregnancy. However, due to the retrospective design, future work is needed to evaluate the role of AMR in the prescriber’s treatment decision-making process.

Pharmacotherapeutic advances for recurrent urinary tract infections in women

INTRODUCTION

Treatment of recurrent Urinary tract infections (UTIs) has become challenging because of the dramatic increase in the rates of recurrent infection andof multidrug-resistant (MDR) infections.

AREAS COVERED

The authors review recurrent UTIs(rUTI) management in women.

EXPERT OPINION

Continuous or post-coital prophylaxis with low-dose antimicrobials or intermittent self-treatment has all been demonstrated to be effective in managing rUTIs in women. Intravaginal estrogen therapy , shows potential toward preventing rUTI. Oral vaccine Uro-Vaxom seems to reduce the number of UTIs. There is evidence that other therapies (e.g. cranberry, Methenamine hippurate, oral D-mannose) may decrease the number of symptomatic UTIs. The treatment of CRE-UTIs is focused on a colistin backbone. Carbapenems are considered first-line agents for UTIs caused by ESBL, but their use is associated with increased MDR. The usage of non-carbapenem for the treatment of ESBL UTIs is necessary. Cefepime, Piperacillin-Tazobactam, Ceftolozane-Tazobactam, and Ceftazidime-Avibactam are justified options. Oral therapy with Pivmecillinam, Fosfomycin, and Nitrofurantoin can be used against uncomplicated UTIs due to ESBL infection.

Magnitude and Its Associated Factors of Urinary Tract Infection among Adult Patients Attending Tigray Region Hospitals, Northern Ethiopia, 2019

BACKGROUND

Urinary tract infection is a major public health problem in terms of morbidity and mortality worldwide. It ranks as the number one infection which leads to an antibiotic prescription after a physician's visit. However, there are limited studies done on UTI in Ethiopia. Hence, this study was aimed to assess the magnitude of urinary tract infection and its associated factors among adult patients attending hospitals of the Tigray region, Ethiopia. Methods and Material. A hospital-based cross-sectional study was conducted from April to May 2019. Systematic random sampling technique was used to select 472 participants from five randomly selected hospitals in Tigray region. A pretested structured questionnaire through face-to-face interview and patient chart review checklist was used to collect data. Data were analyzed by SPSS version 21. A binary logistic regression model was used to test the association between dependent and independent variables.

RESULT

The magnitude of urinary tract infection was 86 (18.2%) (95% CI: 14.6%-21.6%). After adjustment of the independent variables, the significant factors associated with urinary tract infection were being female (AOR = 3.50; 95% CI: 1.88-6.51), urine passing frequency < five times in a day (AOR = 2.32; 95% CI: 1.08-4.96), having diabetes mellitus (AOR = 4.03; 95% CI: 1.69-9.63), history of urinary tract infection (AOR = 4.40; 95% CI: 2.31-8.39), <7 glasses of water intake per day (AOR = 2.16; 95% CI: 1.02-4.58), and history of urinary obstructive diseases (AOR = 2.67; 95% CI: 1.03-6.90). Conclusion and Recommendation. The magnitude of urinary tract infection was considerably high. The factors associated with urinary tract infection were sex, less urine passing frequency, diabetes mellitus, low water intake, history of urinary tract infection, and urinary obstructive diseases. Therefore, patients having DM, previous history of UTI, and urinary obstructive diseases should be routinely screened for urinary tract infection and provided with education on voiding urine at least five times a day and on increasing daily water intake.

IHF stabilizes pathogenicity island I of uropathogenic Escherichia coli strain 536 by attenuating integrase I promoter activity

Pathogenicity islands (PAIs) represent horizontally acquired chromosomal regions and encode their cognate integrase, which mediates chromosomal integration and excision of the island. These site-specific recombination reactions have to be tightly controlled to maintain genomic stability, and their directionality depends on accessory proteins. The integration host factor (IHF) and the factor for inversion stimulation (Fis) are often involved in recombinogenic complex formation and controlling the directionality of the recombination reaction. We investigated the role of the accessory host factors IHF and Fis in controlling the stability of six PAIs in uropathogenic Escherichia coli strain 536. By comparing the loss of individual PAIs in the presence or absence of IHF or Fis, we showed that IHF specifically stabilized PAI I₅₃₆ and that in particular the IHFB subunit seems to be important for this function. We employed complex genetic studies to address the role of IHF in PAI I₅₃₆-encoded integrase (IntI) expression. Based on different YFP-reporter constructs and electrophoretic mobility shift assays we demonstrated that IntI acts a strong repressor of its own synthesis, and that IHF binding to the intI promoter region reduces the probability of intI promoter activation. Our results extend the current knowledge of the role of IHF in controlling directionality of site specific recombination reactions and thus PAI stability.

Differential epidemiology and antibiotic resistance of lactose-fermenting and non-fermenting Escherichia coli: Is it just a matter of taste?

Urinary tract infections (UTIs) are some of the most common infections affecting humans worldwide. Occurrence of atypical, lactose non-fermenting, biochemically "inactive" strains of E. coli in clinical material has been described in the literature, which may cause a significant diagnostic challenge. The present retrospective microbiological study was carried out using isolates and data collected between January 1, 2013, and December 31, 2017, at the Institute of Clinical Microbiology. n = 24,285 positive urine samples were noted during the study period, out of which, samples positive for either lac + and lac- E. coli were included in the analysis. E. coli represented n = 7075 (55.8% ± 4.6%) of outpatient and n = 4916 (42.4% ± 3.6%) of inpatient isolates. n = 401 (3.3%; 80.2 ± 14.6/year) lac- E. coli isolates were identified from urinary tract infections. The ratio of lac- E. coli isolates was significantly higher in outpatient samples (262 vs. 139). Resistance levels of lac- isolates for antibiotics commonly used for treating UTIs were significantly higher for both inpatient and outpatient isolates: norfloxacin, ciprofloxacin, fosfomycin and nitrofurantoin. It is essential to pay attention to the presence of lac- strains, and their omission from clinical material during diagnostic procedures may have significant consequences for epidemiological studies and therapy.

Advances in Understanding the Human Urinary Microbiome and Its Potential Role in Urinary Tract Infection

Recent advances in the analysis of microbial communities colonizing the human body have identified a resident microbial community in the human urinary tract (UT). Compared to many other microbial niches, the human UT harbors a relatively low biomass. Studies have identified many genera and species that may constitute a core urinary microbiome. However, the contribution of the UT microbiome to urinary tract infection (UTI) and recurrent UTI (rUTI) pathobiology is not yet clearly understood. Evidence suggests that commensal species within the UT and urogenital tract (UGT) microbiomes, such as Lactobacillus crispatus, may act to protect against colonization with uropathogens. However, the mechanisms and fundamental biology of the urinary microbiome-host relationship are not understood. The ability to measure and characterize the urinary microbiome has been enabled through the development of next-generation sequencing and bioinformatic platforms that allow for the unbiased detection of resident microbial DNA. Translating technological advances into clinical insight will require further study of the microbial and genomic ecology of the urinary microbiome in both health and disease. Future diagnostic, prognostic, and therapeutic options for the management of UTI may soon incorporate efforts to measure, restore, and/or preserve the native, healthy ecology of the urinary microbiomes.