Bacteriuria Research Articles

Implementation of an intervention to reduce urine dipstick testing in aged care homes: a qualitative study of enablers and barriers, and strategies to enhance delivery

ObjectiveThe ‘To Dip or Not to Dip’ (TDONTD) intervention aims to reduce antibiotic prescribing for urinary tract infection (UTI) by reducing low-value dipstick testing. The aims of this study were...

"Electronic Phenotyping" Antimicrobials to Facilitate Outpatient Stewardship for Asymptomatic Bacteriuria and Urinary Tract Infection in Renal Transplant.

Asymptomatic bacteriuria and urinary tract infection in renal transplant are important antimicrobial stewardship targets but are difficult to identify within electronic medical records. We validated an "electronic phenotype" of antibacterials prescribed for these indications. This may be more useful than billing data in assessing antibiotic indication in this outpatient setting.

Pregnancy after kidney transplantation: clinical features, complications and outcomes

Pregnancy after kidney transplantation (KT) has become more common, but the risk of complications and adverse obstetric outcomes in this group of women remains high.Objective: to study pregnancy complications and outcomes in kidney recipients and renal graft (RG) survival after childbirth.Material and methods. The study included 22 pregnancies in 20 women with RG (transplants performed in 2006–2020). The comparison group consisted of 20 healthy women who had 20 pregnancies. Frequency and nature of pregnancy complications, neonatal health indicators, and pregnancy outcomes were evaluated. Graft survival was compared in the main group and in a group of 102 women after KT who did not have pregnancies.Results. Compared with healthy women, RG recipients had a higher rate of preeclampsia (25% and 0%, p = 0.047), fetal growth restriction (30% and 0%, p = 0.020), gestational diabetes (40% and 5%, p = 0.020), asymptomatic bacteriuria (35% and 5%, p = 0.044), preterm birth (60% and 0%, p < 0.001), and cesarean section (70% and 10%, p < 0.001). Median gestational age and birth weight were significantly lower in women with RG: 36.0 [33.9; 37.4] vs. 38.9 [38.9; 39.6] weeks, p < 0.001, and 2405 [2023; 2958] vs. 3355 [3200; 3690] g, p < 0.001, respectively. The rate of favorable pregnancy outcomes after KT was 81.8%, or 90% when early pregnancy loss is excluded. Two children were found to have genetic diseases passed from the mother. Graft survival did not differ between RG recipients with and without pregnancy, p = 0.272.Conclusions. Pregnancy outcomes in patients with RG are generally favorable, pregnancy and childbirth do not affect graft survival. When planning pregnancy after KT, it is necessary to consider the risk of complications and the possibility of transmitting genetic disorders to offspring.

Impact of altered mental status on antibiotic prescribing and outcomes in hospitalized patients presenting with pyuria

BackgroundPyuria is nonspecific and may result in over-treatment of asymptomatic bacteriuria (ASB). The Infectious Diseases Society of America recommends against antibiotic treatment of ASB for most patients including those presenting with altered mental status (AMS). Close observation is recommended over treatment to avoid missing alternative causes of AMS and overuse of antibiotics resulting in adverse events and resistance. ObjectivesThe purpose of this study was to evaluate patient outcomes associated with antibiotic treatment of pyuria in patients presenting with AMS at hospital admission without specific urinary tract infection (UTI) symptoms. The primary objective was to compare 30-day readmission rates of patients with pyuria and AMS treated with antibiotics (AMS+Tx) versus those who were not treated (AMS-NoTx). Secondary outcomes included identifying risk factors for antibiotic treatment, comparing alternative diagnoses for AMS, and comparing safety outcomes. MethodsThis retrospective cohort study evaluated adult patients with AMS and pyuria (10 WBC/hpf) admitted between February 1, 2020 and October 1, 2021, in a 350-bed community teaching hospital. Patients with documented urinary symptoms were excluded. Additional exclusion criteria included admission to critical care, history of renal transplant, urological surgery, coinfections, pregnancy, and neutropenia. ResultsTwo-hundred patients were included (AMS+Tx, n = 162; AMS-NoTx, n=38). There was no difference in 30-day hospital readmission rate for AMS between groups (AMS+Tx 16.7% vs AMS-NoTx 23.7%, P = 0.311). An alternative diagnosis of AMS occurred more frequently when antibiotics were withheld (AMS+Tx 66% vs. AMS-NoTx 86.8%, P = 0.012). Urinalyses showing bacteria (odds ratio 2.52; 95% CI, 1.11-5.731) and positive urine culture (OR 3.36; 95% CI, 1.46-7.711) were associated with antibiotic prescribing. ConclusionsInappropriate antibiotic use is common among hospitalized patients presenting with AMS and pyuria; however, treatment of asymptomatic pyuria did not decrease rates of subsequent readmission for AMS or retreatment of symptomatic UTI. Patients who were monitored off antibiotics had higher rates of alternative AMS diagnosis.

Urine Characteristics in Pregnant Women with Asymptomatic Bacteriuria

Urine Characteristics in Pregnant Women with Asymptomatic Bacteriuria

Proposing the "Continuum of UTI" for a Nuanced Approach to Diagnosis and Management of Urinary Tract Infections.

Patients with suspected UTIs are categorized into 3 clinical phenotypes based on current guidelines: no UTI, asymptomatic bacteriuria (ASB), or UTI. However, all patients may not fit neatly into these groups. Our objective was to characterize clinical presentations of patients who receive urine tests using the "continuum of UTI" approach. This was a retrospective cohort study of a random sample of adult noncatheterized inpatient and emergency department encounters with paired urinalysis and urine cultures from 5 hospitals in 3 states between January 01, 2017, and December 31, 2019. Trained abstractors collected clinical (eg, symptom) and demographic data. A focus group discussion with multidisciplinary experts was conducted to define the continuum of UTI, a 5-level classification scheme that includes 2 new categories: lower urinary tract symptoms/other urologic symptoms and bacteriuria of unclear significance. The newly defined continuum of UTI categories were compared to the current UTI classification scheme. Of 220,531 encounters, 3392 randomly selected encounters were reviewed. Based on the current classification scheme, 32.1% (n = 704) had ASB and 53% (n = 1614) did not have a UTI. When applying the continuum of UTI categories, 68% of patients (n = 478) with ASB were reclassified as bacteriuria of unclear significance and 29% of patients (n = 467) with "no UTI" were reclassified to lower urinary tract symptoms/other urologic symptoms. Our data suggest the need to reframe our conceptual model of UTI vs ASB to reflect the full spectrum of clinical presentations, acknowledge the diagnostic uncertainty faced by frontline clinicians, and promote a nuanced approach to diagnosis and management of UTIs.

Decision-making and Treatment Preferences Surrounding Bacteriuria in Nonpregnant Women: A Qualitative Investigation.

Best practices suggest nontreatment for asymptomatic bacteriuria in a nonpregnant population, yet there is little literature on patient preference or understanding of asymptomatic bacteriuria treatment. We hypothesize that there might be core factors that affect antibiotic preferences and care-seeking decisions for urinary tract infection and asymptomatic bacteriuria in a postmenopausal population. We performed semi-structured interviews with postmenopausal individuals who had been previously treated for at least one patient-reported urinary tract infection. Interviews covered a discussion about their approach to seeking antibiotics for management and knowledge/preferences for asymptomatic bacteriuria management. Two authors independently coded the interviews and identified a set of symptom-related knowledge and experiences that relate to care-seeking and treatment preferences. We then graphically represented a mental model of antibiotic-seeking practices as an influence diagram, illustrating how knowledge and values affect preferences for care. We performed 30 interviews of participants with a mean age of 69.4 (SD 6.4). Among participants, there were four core factors that influence antibiotic seeking for bacteriuria. Participants noted concern for sequelae from untreated bacteria as their primary motivation, but also noted past experiences, information sources, and testing results as themes that affected their mental model surrounding bacteriuria treatment. The cognitive approach to care-seeking and treatment preference for bacteriuria is influenced by a few central factors. An improved ability to allay concerns either by provider discussions or educational materials are necessary to bridge the gap from the existence of evidence-based guidelines to patient and provider comfort with adherence to these guidelines.

Antimicrobial Agent Use for Urinary Tract Infection in Long-Term Care Facilities in Spain: Results from a Retrospective Analytical Cohort Analysis.

Urinary tract infections (UTIs) are highly prevalent in long-term care facilities, constituting the most common infection in this setting. Our research focuses on analyzing clinical characteristics and antimicrobial prescriptions for UTIs in residents across nursing homes (NH) in Spain. This is a retrospective analytical cohort analysis using a multifaceted approach based on the normalization process theory to improve healthcare quality provided by nursing staff in 34 NHs in Spain. In this study, we present the results of the first audit including 719 UTI cases collected between February and April 2023, with an average age of 85.5 years and 74.5% being women. Cystitis and pyelonephritis presented distinct symptom patterns. Notably, 6% of asymptomatic bacteriuria cases were treated. The prevalence of dipstick usage was 83%, and that of urine culture was only 16%, raising concerns about overreliance, including in the 46 asymptomatic cases, leading to potential overdiagnosis and antibiotic overtreatment. Improved diagnostic criteria and personalized strategies are crucial for UTI management in NHs, emphasizing the need for personalized guidelines on the management of UTIs to mitigate indiscriminate antibiotic use in asymptomatic cases.

Assessing clinicians' and trainees' knowledge and practice of the IDSA guidelines for asymptomatic bacteriuria in older adults.

A survey of advanced practice clinicians (APCs), physicians, residents, and medical students at an academic medical center and community practices in southeastern Texas revealed a gap in knowledge and practice related to testing and treatment for asymptomatic bacteriuria (ASB) in older adults.

The rise, fall, and resurgence of phage therapy for urinary tract infection

ABSTRACT In the face of rising antimicrobial resistance, bacteriophage therapy, also known as phage therapy, is seeing a resurgence as a potential treatment for bacterial infections including urinary tract infection (UTI). Primarily caused by uropathogenic Escherichia coli , the 400 million UTI cases annually are major global healthcare burdens and a primary cause of antibiotic prescriptions in the outpatient setting. Phage therapy has several potential advantages over antibiotics including the ability to disrupt bacterial biofilms and synergize with antimicrobial treatments with minimal side effects or impacts on the microbiota. Phage therapy for UTI treatment has shown generally favorable results in recent animal models and human case reports. Ongoing clinical trials seek to understand the efficacy of phage therapy in individuals with asymptomatic bacteriuria and uncomplicated cystitis. A possible challenge for phage therapy is the development of phage resistance in bacteria during treatment. While resistance frequently develops in vitro and in vivo , resistance can come with negative consequences for the bacteria, leaving them susceptible to antibiotics and other environmental conditions and reducing their overall virulence. “Steering” bacteria toward phage resistance outcomes that leave them less fit or virulent is especially useful in the context of UTI where poorly adherent or slow-growing bacteria are likely to be flushed from the system. In this article, we describe the history of phage therapy in treating UTI and its current resurgence, the state of its clinical use, and an outlook on how well-designed phage therapy could be used to “steer” bacteria toward less virulent and antimicrobial-susceptible states.

Impact of restrictive urinalysis reflex to culture criteria at a large community hospital

Treatment of asymptomatic bacteriuria (ASB) is a common, but often unnecessary, practice. Our objective was to determine the impact of restrictive urinalysis reflex to culture (UARC) criteria on rate of urine cultures (UC) ordered and ASB treatment. Criteria were modified from positive leukocyte esterase, positive nitrites, or white blood cells (WBC) >10 cells to only WBC >10 cells.This pre-post study evaluated UARCs ordered in the emergency department or inpatient units. The primary outcome was the proportion of reflex UCs prevented. Secondary outcomes included the frequency of repeat UARCs and stand-alone UCs, gram-negative rod (GNR) bacteremia, and ASB treatment.In the pre-intervention, there were 4761 UARCs compared to 5420 in the post-intervention; 37.9 % and 21.4 % reflexed to UCs, a 43.5 % reduction in UCs. The rate of repeat UARCs, stand-alone UCs, and GNR bacteremia in the pre- and post-interventions were similar. ASB treatment rate was numerically lower in the post-intervention.

Inappropriate antibiotic initiation for suspected urinary tract infection: a multicenter study comparing psychiatric vs. nonpsychiatric hospital admissions

Differentiating between urinary tract infection (UTI) and asymptomatic bacteriuria is challenging in patients with altered mental status (AMS) and/or decompensated psychiatric illness. The purpose of this multicenter, retrospective cohort study was to identify the extent, patterns, and predictors of inappropriate antibiotic initiation for UTI (IAI-U) within an 18-hospital health system comprising of behavioral health units. Patient-specific factors were evaluated as predictors for IAI-U using descriptive, bivariate and multivariate regression with two-tailed alpha= 0.05. A total of 150 patients were included for data analysis, half of which were admitted for psychiatric evaluation. Almost half of patients (42.7%) had IAI-U, with a nearly even split between IAI-U occurring in the emergency department vs. following hospital admission. There was no statistical difference in IAI-U between patients admitted primarily for a psychiatric diagnosis compared to those with a non-psychiatric diagnosis (46.7% vs. 38.7% respectively, p = 0.32). Factors associated with IAI-U were female sex (OR 5.83, 95% CI: 1.73–19.71; p = 0.005) and being discharged to skilled nursing facilities (OR 11.77, 95%: CI 2.11–65.48; p = 0.005). This exploratory analysis suggests IAI-U occurs frequently in the various subgroups evaluated, even those where no association was found. These findings demonstrate an ongoing urgent need for interventions to reduce IAI-U across all sectors of inpatient health systems. Future large-scale studies are needed to fully evaluate these findings across health care systems and specialty acute care settings.

P08 An usual case of pandrug-resistant Serratia marcescens in a 63 year-old-male: a case report

Abstract Objectives To highlight the growing burden of antimicrobial resistance in developing countries where there are no officially agreed local antibiotics guidelines. We are characterizing a case of growth of pandrug-resistant (PDR) Serratia marcescens in the urine culture of a 63-year-old-male. Patient and methods Our patient, who had a history of recurrent renal stones, underwent multiple urological procedures (including ureteroscopy and DJ stenting) in various regional hospitals in northern Pakistan. It is postulated that he became infected during these repeated procedures which were done in various hospitals without adequate sterile equipment. He presented with recurrent UTIs to GPs and was subsequently treated with oral fosfomycin for over 1 year in total. His baseline renal function remains unknown due to the absence of online records, but he was noted to have CKD IV. Subsequently, during his later visits to the hospital, he developed sepsis and his urine cultures confirmed carbapenem-resistant Pseudomonas aeruginosa, which was treated with IV antibiotics as per the susceptibility report. He was prescribed IV piperacillin/tazobactam (Tazocin) for a total period of 3 months on various occasions due to repeated presentations with urosepsis. He improved clinically with IV piperacillin/tazobactam. Following this, the patient was lost to follow-up. The patient once again presented acutely unwell with urosepsis. This time urine cultures confirmed the presence of S. marcescens (May 2023). The patient had pandrug resistance to all antibiotics including IV piperacillin/tazobactam. However it was decided to treat him with IV piperacillin/tazobactam due to previous good results. The patient improved clinically but his renal functions declined to CKD stage V. He was once again lost to follow up. He presented again to renal consultants with uraemic symptoms and at the moment he is being counselled for dialysis due to his end-stage renal disease. At present the patient is having asymptomatic bacteriuria; his urine cultures remain positive without any symptoms. A more recent urine culture (September 2023) showed growth of Escherichia coli (ESBL). Due to lack of symptoms, renal consultants agreed to manage the patient without further antibiotics. Results In May 2023, an antibiotic susceptibility profile was done under supervision of microbiologists. Unfortunately for the patient, the urine culture reported growth of S. marcescens and that the patient had pandrug-resistance. The profile included testing for the following antibiotics: amikacin, co-amoxiclav, aztreonam, cefepime, cefoxitin, ceftazidime/avibactam, cefalexin, co-trimoxazole, fosfomycin, meropenem, amoxicillin, ampicillin, cefaclor, cefixime, cefpodoxime, cefuroxime, ciprofloxacin, colistin, imipenem, nitrofurantoin, norfloxacin, polymyxin, piperacillin/tazobactam and sulbactam/cefoperazone. In September 2023, the second urine culture report with the growth of E. coli showed susceptibility to amikacin, cefoperazone/sulbactam, fosfomycin, imipenem and tigecycline. This report also confirmed resistance co-amoxiclav, ampicillin, cefixime, cefotaxime, ceftazidime, ceftriaxone, cefuroxime, cefradine, levofloxacin, nalidixic acid, nitrofurantoin, piperacillin/tazobactam and trimethoprim/sulfamethoxazole. Conclusions Unfortunately, the urine culture and susceptibility report signify the threat this patient faces in case he develops further urine infections. It is imperative to encourage development of local guidelines in developing countries too. We would recommend a multidisciplinary approach in treating difficult and long-term infections with constant support of microbiologists.

Asymptomatic bacteriuria and its associated fetomaternal outcomes among pregnant women delivering at Bugando Medical Centre in Mwanza, Tanzania.

Asymptomatic bacteriuria (ASB) affects 23.9% of pregnant women globally and, if left untreated, can lead to adverse fetomaternal outcomes. In Tanzania, ASB prevalence has ranged from 13% to 17% over the past decade. Yet, its impact on fetomaternal outcomes remains unexplored, hindering the development of screening strategies, antimicrobial therapies, and preventive measures for this vulnerable population. A cross-sectional analytical study was conducted on 1,093 pregnant women admitted for delivery at Bugando Medical Center (BMC) in Mwanza, Tanzania, from July to December 2022. Socio-demographic, obstetric, and clinical data were collected from the women, along with mid-stream urine samples for analysis. Fetomaternal outcomes were assessed within 72 hours after delivery. The median age of participants was 29 years (range: 15-45 years). ASB prevalence among pregnant women was 16.9% (185/1093), with a 95% CI of 14.6-19.3%. Risk factors for ASB included anemia (OR: 5.3; 95% CI = 3.7-8.2, p-value <0.001) and a history of antenatal care admission (OR 4.2; 95% CI = 2.9-6.1, p-value <0.001). Among all participants, 82 (7.5%), 65 (5.9%), 49 (4.5%), and 79 (7.2%) experienced pre-term labor (PTL), premature rupture of membrane (PROM), preeclampsia, and delivered newborns with low birthweight (LBW), respectively. Among the 185 patients with ASB, the respective proportions of PTL, PROM, preeclampsia, and LBW were 25.4%, 17.3%, 9.2%, and 12.4%. Multivariable logistic regression analysis revealed significant associations between ASB and PTL [OR (95% CI): 8.8 (5.5-14.5); p-value <0.001], PROM [OR (95% CI): 4.5 (2.5-8.0); p-value <0.001], and LBW [OR (95% CI): 2.0 (1.2-3.5); p-value = 0.011]. Escherichia coli (50.8%) and Klebsiella pneumoniae (14.05%) were the most common pathogens, with low resistance rates to nitrofurantoin, amoxicillin-clavulanate, and cephalosporins-antibiotics considered safe during pregnancy-ranging from 8.2% to 31.0%. The prevalence of ASB among pregnant women in Tanzania remains high and is associated with adverse fetomaternal outcomes. Integrating routine urine culture screening for all pregnant women, irrespective of symptoms, and providing specific antimicrobial therapies during antenatal care can help prevent adverse pregnancy outcomes.

To treat or not to treat asymptomatic bacteriuria in renal transplant patients, A systematic review

Background: Antibiotic therapy as a preventative measure for asymptomatic bacteriuria (AB) in kidney recipients can be beneficial in reducing subsequent symptomatic infections. Treating AB and acute graft pyelonephritis is crucial for reducing the risk of graft rejection after kidney transplantation, However, the effectiveness of antibiotics in these cases is still debate in the medical community. Objectives: This review aims to determine the benefits and risks of treating AB in kidney transplant recipients with antimicrobial agents to prevent symptomatic urinary tract infection (UTI) and all-cause mortality. Methods: The review included 10 articles published form January 2010 to January 2021 which examined the effectiveness of treating AB after renal transplantation. Results: AB treatment with antibiotics was found to have no benefit in all reviewed studies, as antibiotic treatment of AB increase the emergence of more resistant organisms in urine. During the months of follow-up, it was also a risk factor for UTI. Conclusion: Sufficient evidence has shown that AB treatment with antibiotics does not provide any significant benefit in the short and long term. Giving these findings, considering other important treatment options is vital to improve clinical outcome for this condition.

Asymptomatic Bacteriuria in Antenatal Cases: A Cross-sectional Study from Southern Rajasthan, India

Introduction: Due to various anatomical and physiological changes during pregnancy, women are more prone to develop Urinary Tract Infections (UTI), which may progress to involve the upper urinary tract resulting in acute pyelonephritis, or may involve the lower tract resulting in acute cystitis. Aim: To study Asymptomatic Bacteriuria (ASB) in antenatal cases and to isolate, identify, and establish the antimicrobial susceptibility pattern of the pathogens responsible for ASB. Materials and Methods: This cross-sectional study was conducted from January 2020 to December 2020 on 363 antenatal cases attending Obstetrics Outpatient Department (OPD) in RNT Medical College, Udaipur, Rajasthan, India. The samples were processed within one hour of collection and tested (samples were cultured, and Gram’s staining and wet mount were done) for the presence of significant ASB and the sensitivity pattern of the isolates. The statistical analysis of the variables was assessed using the odds ratio and a p-value &lt;0.05 was considered significant. Results: A total of 363 samples were evaluated; 44 samples showed significant bacteriuria in culture, with the most commonly isolated organism being Enterococcus faecalis 25 (56.8%), followed by Escherichia coli 14 (31.8%), Klebsiella pneumoniae 2 (4.5%), Enterococcus faecium 2 (4.5%), and Pseudomonas species 1 (2.3%). Gram-positive isolates were highly sensitive to amoxyclav, nitrofurantoin, vancomycin, linezolid, and imipenem, while showing reduced sensitivity to amoxicillin and nalidixic acid. Gram-negative isolates were highly sensitive to gentamicin, ceftaclav, cefoperazone- sulbactam, piperacillin-tazobactam, linezolid, vancomycin and imipenem and showed the least sensitivity to amoxicillin, cephalexin, and ceftriaxone. Conclusion: To prevent serious complications in both the mother and the foetus, urine culture and antimicrobial sensitivity testing by Kirby-Bauer disk diffusion method in the first and second trimester in antenatal women should be done as a routine procedure for the early diagnosis of ASB.

Molecular investigate of slim and adhesion genes of Staphylococcus saprophyticus isolated from pregnant women with asymptomatic bacteriuria in Thi-Qar governorates.

Aims: to investigate and compared the frequency of biof i lm formation ica A and adhesion genes clf A, cnaA, fnbA and fnbB in chromosome and plasmid of S. saprophyticus. Materials and methods: 48 isolates about S. saprophyticus were selective randomly from total 1019 isolated from pregnant women with asymptomatic bacteriuria where the samples were collected in AL Habboby Hospital and Al-Hussein teaching, and bent Al-Huda hospitals from the fi rst of April 2022 until the fi rst of September 2023 and bacteria of study were identif i ed depend on previous method. Results: PCR appeared, higher existence percentage of study virulence factors genes was in chromosome that reached 399.9% of study bacteria, more than in its in plasmid 66.5%, however the frequency rate of study genes in chromosome was as following: ica A and fnb A genes were complete, 100% (48/48), while cna A and clf A genes percentage were identical and came in second grade that arrived signif i cant rate 83.3% (40/48), the lowest results were showed 33.3% (16/48) isolates harbored fnb B gene, while they were decreased in its plasmid as following: ica A and fnb A genes were 12.5% (6/48) and 22.9% (11/48) respectively, the cna A and clf A genes percentage 6.2 % (3/48) and 4.1% (2/48) respectively, fnb B gene 20.8% (10/48). Conclusions: Depend on above data may be ica A, fnb A, clf A, cna A genes more occurrence in comparison to fnb B genes among S. saprophyticus and plasmid may double the rate of same virulence study genes.

Inappropriate treatment of asymptomatic bacteriuria

Asymptomatic bacteriuria is frequently encountered in clinical practice and should be treated only in pregnant women and before invasive urological procedures. Inappropriate treatment of asymptomatic bacteriuria is associated with numerous adverse effects including allergic reactions, increased antibiotics resistance and increase risk of Clostridioides difficile infection. Positive urinary culture often leads to antimicrobial treatment, irrespective of urinary symptoms. Therefore, urine analysis and culture should be performed only in symptomatic individuals or in asymptomatic individuals with a clear indication for treatment.

Nekomplikovane infekcije mokraćnih puteva kod starih osoba

A healthy urinary tract is not a sterile environment but is inhabited by diverse microorganisms that change according to environmental factors and the patient's condition. Elderly patients are predisposed to urinary tract infections and asymptomatic bacteriuria, and distinguishing between these two conditions is challenging. They are specific in several issues: the pathogenesis of infection and causative agents, diagnostic procedures, applied therapy, and preventive measures. Proper interpretation of symptoms, sampling of materials for analysis, and interpretation of results are of great importance. Correct procedures allow sparing patients from unnecessary treatment and complications of antibiotic therapy, as well as reducing bacterial resistance.

Bring it on again: antimicrobial stewardship in transplant infectious diseases: updates and new challenges.

Advancement in solid organ transplantation and hematopoietic stem cell transplant continues to improve the health outcomes of patients and widens the number of eligible patients who can benefit from the medical progress. Preserving the effectiveness of antimicrobials remains crucial, as otherwise transplant surgeries would be unsafe due to surgical site infections, and the risk of sepsis with neutropenia would preclude stem cell transplant. In this review, we provide updates on three previously discussed stewardship challenges: febrile neutropenia, Clostridioides difficile infection, and asymptomatic bacteriuria. We also offer insight into four new stewardship challenges: the applicability of the "shorter is better" paradigm shift to antimicrobial duration; antibiotic allergy delabeling and desensitization; colonization with multidrug-resistant gram-negative organisms; and management of cytomegalovirus infections. Specifically, data are accumulating for "shorter is better" and antibiotic allergy delabeling in transplant patients, following successes in the general population. Unique to transplant patients are the impact of multidrug-resistant organism colonization on clinical decision-making of antibiotic prophylaxis in transplant procedure and the need for antiviral stewardship in cytomegalovirus. We highlighted the expansion of antimicrobial stewardship interventions as potential solutions for these challenges, as well as gaps in knowledge and opportunities for further research.