Clinical impacts and management of urinary tract infections caused by extended-spectrum beta-lactamaseproducing Enterobacteriaceae in children: a narrative review

BackgroundPharmacist-led management of urinary tract infections has been introduced as a service in the United Kingdom, Canada, United States of America, New Zealand, and Australia. The management of acute uncomplicated urinary tract infections by community pharmacists has gained increasing attention as a potential avenue to alleviate the burden on primary healthcare services.AimThe objectives of the review were to: (1) identify protocols for community pharmacist management of acute uncomplicated urinary tract infections in women aged 16–65 years; (2) outline their key components; and (3) appraise the quality of protocols.MethodA grey literature search was undertaken for protocols intended for use by community pharmacists for the management of acute uncomplicated urinary tract infections in women aged 16–65 years, met the definition of a clinical management protocol and written in English. Their quality was appraised using the Appraisal Guidelines for Research and Evaluation version II instrument.ResultsForty of the 274 records screened were included. Content analysis identified ten key components: common signs/symptoms, differential diagnosis, red flags/referral, choice of empirical antibiotic therapy, nonprescription medications, nonpharmacological/self-care advice, patient eligibility criteria, patient follow-up, dipstick testing recommendations, and recommendations on antimicrobial resistance. The lowest scoring domains in the quality assessment were ‘Editorial Independence’ and ‘Rigour of Development’. Only four protocols were deemed high-quality.ConclusionThe review demonstrates that clinical management protocols for pharmacist-led management of urinary tract infections consist of similar recommendations, despite variation in international practice. However, the findings highlight a deficiency in the quality of most clinical management protocols governing pharmacist-led urinary tract infection management.

MANAGEMENT OF URINARY TRACT INFECTIONS: HISTORICAL PERSPECTIVE AND CURRENT STRATEGIES: PART 2— MODERN MANAGEMENT

BackgroundThere is a lack of consensus in treating infants with extended-spectrum beta-lactamase producing Enterobacteriaceae (ESBL-E) urinary tract infection (UTI) who demonstrate good clinical response to initial antibiotics within 48 h.MethodsWe conducted an international survey among paediatric nephrologists and fellows in training using a web-based questionnaire.ResultsA total of 232 centres across 77 countries participated in the survey. Second- or third-generation cephalosporins were the initial antibiotic of choice upon presentation in 63.8% of the centres. If the ESBL-E isolated from urine culture demonstrated in vitro susceptibility, 81.0% of respondents would continue the initial oral antibiotics. In contrast, there was considerable practice variation in the presence of in vitro resistance to the initial oral antibiotic. 19.0% would switch to a carbapenem group antibiotic, while 49.6% would change to a non-carbapenem antibiotic according to the sensitivity profiles. 22.8% would continue initial antibiotics based on satisfactory clinical response. The remaining 8.6% would choose other options. Similar emphasis on in vitro susceptibility result for the treatment was observed among centres who treated patients with intravenous antibiotics at UTI presentation. In the presence of a UTI with an ESBL-E, 50.0% centres would perform additional radiological investigations, and 61.2% would offer antibiotic prophylaxis to prevent further UTIs.ConclusionThere are significant variations in the management of UTI caused by ESBL-E bacteria between centres. In vitro susceptibility to the antibiotics remains an important management consideration. Antibiotics from the non-carbapenem groups seem to be the preferred option. Further studies are required to identify the optimal treatment regimen in this patient population.Graphical abstractA higher resolution version of the Graphical abstract is available as Supplementary information

The diagnosis and management of urinary tract infections (UTIs) in young children are clinically challenging. This report was developed to inform the revised, evidence-based, clinical guideline regarding the diagnosis and management of initial UTIs in febrile infants and young children, 2 to 24 months of age, from the American Academy of Pediatrics Subcommittee on Urinary Tract Infection. The conceptual model presented in the 1999 technical report was updated after a comprehensive review of published literature. Studies with potentially new information or with evidence that reinforced the 1999 technical report were retained. Meta-analyses on the effectiveness of antimicrobial prophylaxis to prevent recurrent UTI were performed. Review of recent literature revealed new evidence in the following areas. Certain clinical findings and new urinalysis methods can help clinicians identify febrile children at very low risk of UTI. Oral antimicrobial therapy is as effective as parenteral therapy in treating UTI. Data from published, randomized controlled trials do not support antimicrobial prophylaxis to prevent febrile UTI when vesicoureteral reflux is found through voiding cystourethrography. Ultrasonography of the urinary tract after the first UTI has poor sensitivity. Early antimicrobial treatment may decrease the risk of renal damage from UTI. Recent literature agrees with most of the evidence presented in the 1999 technical report, but meta-analyses of data from recent, randomized controlled trials do not support antimicrobial prophylaxis to prevent febrile UTI. This finding argues against voiding cystourethrography after the first UTI.

Cystitis Treatment in Women, Circa 2011: New Role for an Old Drug

The incidence of urinary tract infection (UTI) in childhood is highest in infancy and accounts for 5% of febrile infants. Reflux nephropathy following UTI in early childhood is the commonest preventable cause of chronic renal failure. Recent guidelines aim to improve the diagnosis and management of UTI in small children. To assess management of febrile children and UTI in children under 2 years amongst GPs, and to identify some reasons for the difficulties in diagnosing UTI. Questionnaire distributed by periodical journal. Eighty-two GPs responded, of whom 61 (74%) were unaware of the recent Royal College of Physicians guidelines on childhood UTI. Seventy-seven GPs (94%) would find guidelines helpful on when to send a urine sample for culture from a child under 2 years. Only 11 GPs (14%) regularly sent urine from febrile infants and toddlers; 48 GPs (63%) sent urine from only 0-10% of patients; 21 (26%) were unable to collect urine at all from these children. Several difficulties were identified by GPs regarding investigation for UTI in children. These related to practical difficulties in urine collection and culturing, lack of professional awareness of the importance of UTI and concerns about the costs of investigation. GPs frequently do not investigate for UTI in febrile children due to practical difficulties, lack of awareness and financial costs. National guidelines need to be disseminated and implemented effectively to reach target groups. Further scope for research into a simple, cheap method to collect and test urine has been highlighted as a priority to improve early diagnosis of UTI. Management of UTI in primary care can be improved with carefully evaluated strategies and this could lead to a reduction in the prevalence of renal scarring.

BackgroundWe performed this study 1) to determine the prevalence of community-associated extended spectrum beta-lactamase producing Enterobacteriaceae (ESBLPE) colonization and infection in New York City (NYC); 2) to determine the prevalence of newly-acquired ESBLPE during travel; 3) to look for similarilties in contemporaneous hospital-associated bloodstream ESBLPE and travel-associated ESBLPE.MethodsSubjects were recruited from a travel medicine practice and consented to submit pre- and post-travel stools, which were assessed for the presence of ESBLPE. Pre-travel stools and stools submitted for culture were used to estimate the prevalence of community-associated ESBLPE. The prevalence of ESBLPE-associated urinary tract infections was calculated from available retrospective data. Hospital-associated ESBLPE were acquired from saved bloodstream isolates. All ESBLPE underwent multilocus sequence typing (MLST) and ESBL characterization.ResultsOne of 60 (1.7%) pre- or non-travel associated stool was colonized with ESBLPE. Among community-associated urine specimens, 1.3% of Escherichia coli and 1.4% of Klebsiella pneumoniae were identified as ESBLPE. Seven of 28 travelers (25.0%) acquired a new ESBLPE during travel. No similarities were found between travel-associated ESBLPE and hospital-associated ESBLPE. A range of imported ESBL genes were found, including CTX-M-14 and CTX-15.ConclusionESBL colonization and infection were relatively low during the study period in NYC. A signficant minority of travelers acquired new ESBLPE during travel.

A Content Analysis of Mobile Phone Applications for the Diagnosis, Treatment, and Prevention of Urinary Tract Infections, and Their Compliance with European Association of Urology Guidelines on Urological Infections

The aim of this study was to assess the impact of a urinary tract infection (UTI) management bundle to reduce the treatment of asymptomatic bacteriuria (AB) and to improve the management of symptomatic UTIs. Before-and-after intervention study.SettingsTertiary-care hospital.PatientsConsecutive sample of inpatients with positive single or mixed-predominant urine cultures collected and reported while admitted to the hospital. The UTI management bundle consisted of nursing and prescriber education, modification of the reporting of positive urine cultures, and pharmacists' prospective audit and feedback. A retrospective chart review of consecutive inpatients with positive urinary cultures was performed before and after implementation of the management bundle. Prior to the implementation of the management bundle, 276 patients were eligible criteria for chart review. Of these 276 patients, 165 (59·8%) were found to have AB; of these 165 patients with AB, 111 (67·3%) were treated with antimicrobials. Moreover, 268 patients met eligibility criteria for postintervention review. Of these 268, 133 patients (49·6%) were found to have AB; of these 133 with AB, 22 (16·5%) were treated with antimicrobials. Thus, a 75·5% reduction of AB treatment was achieved. Educational components of the bundle resulted in a substantial decrease in nonphysician-directed urine sample submission. Adherence to a UTI management algorithm improved substantially in the intervention period, with a notable decrease in fluoroquinolone prescription for empiric UTI treatment. A UTI management bundle resulted in a dramatic improvement in the management of urinary tract infection, particularly a reduction in the treatment of AB and improved management of symptomatic UTI.

Background: Appropriate antibiotic use has been described as one of the key strategies in tackling antibiotic resistance. Although the majority of antimicrobial therapy is completed following discharge, there lacks clear guidance in addressing antibiotic stewardship in the outpatient setting. Particularly, broader coverage as well as longer durations of therapy are often encountered following hospitalization. In our study we examine the various antibiotic prescribing practices on hospital discharge for management of urinary tract infections (UTI). Methods: We conducted a single-center, retrospective observational chart review of patients discharged from St. Francis Hospital and Medical Center in Hartford between May and July 2022. Medical records were reviewed for patients who were prescribed antibiotic therapy for management of UTI and met inclusion criteria. Variables of interest included type of UTI treated, antibiotic used, duration of antibiotics during and following hospitalization, fluoroquinolone use, as well reported adverse events. Total duration of therapy was defined as days on susceptible antimicrobials with appropriate source control. Results: A total of 84 patients met inclusion criteria. 44 received treatment for simple UTI (sUTI) and 40 for complicated UTI (cUTI). Figure 1 shows the various organisms identified on culture. The most common antimicrobials prescribed on discharge were cefpodoxime and ciprofloxacin [figure 2]. Quinolones were prescribed in 11.4% of sUTIs and 39.1% of cUTIs on hospital discharge. Of those, only one patient had no alternative to quinolone use due to drug allergies. The mean duration of therapy for treatment of sUTI was 6.4 days total (SD 2.40) with 3.9 days outpatient (SD 1.78). The mean duration of therapy for treatment of cUTI was 10.9 days total (SD 3.62) with 6.7 days outpatient (SD 2.99). Comparison of mean durations is shown in figure 3. In 49% of all cases (including both sUTI and cUTI) patients received greater than 7 days of antimicrobial therapy. Conclusion: There is increased evidence favoring shorter courses of antimicrobial therapy for management of both simple and complicated UTIs. A 7-day course has been shown as effective duration of therapy for cUTI with appropriate source control, regardless of presence of bacteremia. Results from our single center-study show both sUTI and cUTI are subject to unnecessarily prolonged durations of therapy on hospital discharge. In addition we noted a significant use of fluoroquinolones in cUTI treatment. We believe stewardship interventions at time of discharge may particularly benefit shorter courses of therapy for cUTI as well as reduced quinolone use.

Urinary Tract Infections in Solid Organ Transplant Recipients

Value of Ultrasound in Evaluation of Infants With First Urinary Tract Infection

Update and summary of the EAU/ESPU paediatric guidelines on urinary tract infection in children.

Cefepime versus carbapenems for the treatment of urinary tract infections caused by extended-spectrum β-lactamase-producing enterobacteriaceae

* Abbreviations: IV — : intravenous UTI — : urinary tract infection Randomized trials have played a pivotal role in shaping the management of pediatric urinary tract infections (UTIs). In important recent trials, authors have demonstrated that oral antibiotics are as effective as intravenous (IV) antibiotics1 and that prophylactic antibiotics do not prevent renal scarring.2 Given multiple ongoing controversies in the diagnosis and management of UTIs, however, still more trials are needed. In this issue of Pediatrics , Basmaci et al3 report a systematic review of 40 trials published between 1990 and 2016 involving 4381 UTI cases. They highlight the numerous inconsistencies in inclusion criteria and choice of end points in published UTI antibiotic trials and suggest that more uniformity is required. The lack of uniform inclusion criteria across trials reflects an ongoing controversy over the definition of UTI.4 Because of fear that some UTIs will be missed,5 there is reluctance to incorporate pyuria as a diagnostic criterion,6 despite the latest recommendation from the American Academy of Pediatrics UTI clinical practice guideline7 and subsequent supportive data that the urinalysis is more reliable than previously … Address correspondence to Alan R. Schroeder, MD, Department of Pediatrics, Division of Hospital Medicine, Stanford University School of Medicine, 300 Pasteur Dr, MC 5776, Stanford, CA 94305. E-mail: aschroe{at}stanford.edu