Cases Of Asymptomatic Bacteriuria Research Articles

Asymptomatic bacteriuria screening for developing countries using a modified water quality test kit.

Between 2% and 15% of pregnant women unknowingly experience asymptomatic bacteriuria (ASB), defined as ≥105 CFU per milliliter of urine in the absence of symptoms. ASB increases the risk of adverse pregnancy outcomes including pyelonephritis, preterm labor, and low-birth weight infants. While pregnant women in the United States are routinely screened for ASB, those in developing countries with limited resources and funding lack an accurate mechanism for ASB screening. Aquagenx water quality test kits detect Escherichia coli, the most common causative agent of ASB, and total coliform bacteria in drinking water via colorimetric and fluorescent indicators. We found that the Aquagenx system is compatible with human urine and then proceeded to develop an ASB screening protocol using disposable inoculating loops. Our protocol diagnosed artificial ASB- samples (104 CFU/mL E. coli) with a false positive (FP) rate of 33% (n = 18) and ASB+ (105 CFU/mL E. coli) with a false negative (FN) rate of 5.6% (n = 18). Clinical sample testing with our protocol revealed a FP rate of 0% in ASB- samples (n = 28) and a FN rate of 0% in ASB+ samples caused by coliforms (n = 13). Aquagenx did not detect ASB in nine clinical samples with non-coliform etiological agents due to the limitations of the technology. However, with very high accuracy for detection of E. coli and other causative agents that collectively account for 90.1% of ASB cases, these kits could be used as a diagnostic ASB screening tool in developing countries in which there is currently no alternative to urine culture.IMPORTANCEAsymptomatic bacteriuria (ASB) affects 2%-15% of pregnant women and can result in adverse maternal and fetal outcomes if left undetected and untreated. In the United States and other developed nations, pregnant women are regularly screened for ASB via urine culture. However, in low-resource countries where bacterial culture is not available, dipstick testing is used. Although accurate in cases of symptomatic bacteriuria, dipstick detection is ineffective for detecting ASB. Here, we made use of an existing water quality field test for ASB urine screening, which would be readily deployable in low-resource settings. We optimized a dilution protocol for sampling patient urine within the detection limits of the Aquagenx kit technology. Overall, we were able to detect ASB samples with Gram-negative pathogens that collectively account for 90% of all ASB cases. Utilization of this repurposed technology for proactive medical screening may help prevent adverse pregnancy and birth outcomes due to ASB.

When antimicrobial stewardship begins with microbiological test requests: the case of asymptomatic bacteriuria.

We aim to review the rationale, methods, and experiences with diagnostic stewardship targeted at urinary tract infection (UTI) and related urinary syndromes. In the last 18 months, several articles have demonstrated the impact of diagnostic stewardship interventions at limiting inappropriate diagnosis of UTIs or inappropriate antibiotic-prescribing, targeting the urinary tract. Antimicrobial stewardship programs may create and implement interventions at the point of urine test ordering, urine test resulting, or at the point of prescribing antibiotics after results have returned. Specific design and implementation of stewardship interventions depends on context. To maximize their impact, interventions should be accompanied by education and garner buy-in from providers. Diagnostic stewardship can decrease unnecessary antibiotics and inappropriate diagnosis of UTI with multifaceted interventions most likely to be effective. Remaining questions include how to reduce ASB treatment in new populations, such as those with immune compromise, and persistent unknowns regarding UTI diagnosis and diagnostics.

It Takes a Village: Leveraging a Multidisciplinary Team and Technology for Urine Culturing Stewardship

Background: Patients without urinary tract infection (UTI) symptoms but with a positive urine culture are considered to have asymptomatic bacteriuria (ASB). This often represents colonization and treatment is not recommended or clinically beneficial. Treatment of ASB can promote antimicrobial resistance and increased rates of Clostriodies difficile infections. Many cases of ASB are incorrectly assigned as CAUTIs due to over-culturing practices. We hypothesized that a urine culture algorithm, embedded within a best practice alert (BPA) in the electronic medical record (EMR), would reduce urine culturing practices for ASB. Methods: From Feb 2022 through May 2023, a multidisciplinary team implemented an Inpatient Urine Culturing Stewardship Guideline. A BPA fired when a provider placed a urinalysis with reflex to culture (UACC) or urine culture (UC) order for patients who met criteria (Image 1). The BPA directed providers to remove the order, select the appropriate pathway from the guideline, or provide a rationale for placing the order. The intervention was piloted on three intensive care units and two progressive care units, containing both medical and surgical patients. Monthly ordering practices, CAUTI rates, and gram-negative rod (GNR) bacteremia rates from a 13-month pre-intervention baseline period were compared to a 16-month intervention period. Over the same time periods, we also assessed changes in ordering practices for comparison units which did not implement the intervention. Pre-and-post intervention cohorts were analyzed using median two sample tests and Exact Poison Method, as appropriate. Results: On intervention units there was a 41.0% reduction in the median number of UACC and UC orders per 1000 patient days from 16.31 during the baseline period to 9.62 in the intervention period (p=0.0036). Pan cultures per 1000 patient days in which one of the orders was a UACC or UC fell by 42.2% from a median of 10.20 per 1000 patient days to 5.90 (p=0.0008). The comparison units saw no significant reductions in UACC and UC orders (p=0.21) or pan cultures (p=1.0). On the intervention units, the CAUTI rate for the baseline period was 1.31 per 1000 catheter days versus 0.79 in the intervention period (IRR = 1.65; p=0.44). GNR bacteremias remained stable on the intervention units between the baseline and intervention periods (p=0.82). Conclusion: This multidisciplinary intervention, leveraging EMR clinical decision support, reduced urine and pan culturing practices while demonstrating a trend towards a reduced CAUTI rate. The prevalence of GNR bacteremias remained consistent with baseline levels, suggesting the intervention did not cause harm.

Prevalence of Urinary Tract Infections in Hospitalized Diabetic Patients: Insights from a Guntur-A Case Study

Background: The existence of evidence was always given when diabetes predisposes individuals to a higher likelihood of experiencing asymptomatic bacteriuria and urinary tract infections. Urinary tract infections(UTIs) are highly prevalent among individuals with diabetes, emerging as the foremost type of bacterial infection within this demographic. Objective: This study was done to establish the prevalence of urinary tract infections in hospitalized diabetics and the most common causative strains. Materials and Methods: The research samples are consisted of 649 individuals diagnosed with 373 being women and 276 being men. These patients were admitted to the Government General Hospital (GGH), Guntur in various departments such as Urology, Nephrology, and the general ward between January and December 2023. We gathered individuals' personal medical information and conducted urine cultures. For statistical analysis we used Graph Pad Prism 10.2.3; the significance of the difference between the percentage values was assessed using Fisher’s exact test. Results: Among the patients studied, 110 (17%) had positive urine cultures. Of these 110 urinary tract infections, 86 (78.3%) were cases of asymptomatic bacteriuria. Escherichia coli was the most commonly identified bacterium, responsible for 68.9% of the infections. Conclusion: Urinary tract infections are prevalent among diabetic individuals. Given the significant number of asymptomatic cases, it is advisable to conduct urine cultures for all hospitalized diabetic patients.

Development and validation of an antimicrobial stewardship clinical decision-support tool to improve the management of urinary tract infections versus asymptomatic bacteriuria in hospitalized patients.

To assess the effectiveness of a 3-question decision-support tool to guide the diagnosis and treatment of urinary tract infections (UTIs) in acute care hospitalized patients as an antibiotic and diagnostic stewardship initiative. Retrospective cohort study. Four acute care hospitals within the same health system in Miami, FL. 124, admitted from the emergency department and hospitalized adult patients, treated with antibiotics for the indication of a UTI between March and April 2023. We developed a 3-step clinical decision-support tool (CDST) to evaluate the appropriateness of urine cultures and antibiotic treatment. The tool's recommendations when deciding to prescribe antibiotics were compared with the actual need for treatment throughout the hospitalization, up to the time of patient discharge. Overall, 31% of antibiotics prescribed for UTIs were inappropriate and met thecriteria for asymptomatic bacteriuria (ASB) based on the CDST. Prospective implementation of the decision-support tool could potentially reduce antibiotic use by 33.6%, corresponding to 265 days of unnecessary therapy. The sensitivity and specificity of the tool were calculated to be 98.6% and 100%, respectively, indicating high accuracy in identifying the need for antibiotic treatment. Urinalysis alone was insufficient to differentiate between symptomatic UTIs and ASB, with leukocyturia present in 95.3% of UTI cases and 94.6% of ASB cases (P = 0.87). Implementing a 3-question CDST may reduce unnecessary laboratory work-up and treatment for ASB improving the diagnostic and antimicrobial stewardship of UTIs.

Prevalence of urinary tract infection with asymptomatic bacteriuria among gravid females: A Pakistani multicenter cross-sectional study.

Objective: To determine the prevalence of urinary tract infection with asymptomatic bacteriuria among pregnant females. Study Design: Multi-center, Cross-sectional study. Setting: Department of Obstetrics and Gynecology, Jinnah Postgraduate Medical Center, Karachi, Sheikh Zayed Medical College and Hospital, Rahim Yar Khan, and Hayatabad Medical Complex, Peshawar, Pakistan. Period: January 2023 to June 2023. Material & Methods: A total of 260 pregnant females aged between 18 to 45 years and visiting outpatient department for antenatal check-up were analyzed. Enrolled females were interviewed and demographical and clinical data were noted. All women had their urine analysis done as a routine antenatal test. Urine culture analysis was also done at the same time. Asymptomatic bacteriuria was labeled when urine culture revealed the presence of more than 105 bacteria per milliliter of urine but without showing symptoms of urinary tract infections. Results: In a total of 260 pregnant females, the mean age was 28.6±5.3 years (ranging between 18-45 years). There were 125 (48.1%) females who reported during 3rd trimester of pregnancy. Residential status of 209 (80.4%) females was urban. There were 65 (25.0) females who were illiterate. Family monthly income of 198 (76.2%) females was below 30,000 Pakistani Rupees. Asymptomatic bacteriuria was revealed in 69 (26.5%) pregnant females. The most common urinary bacterial isolates were E. coli and Klebsiella found in 36 (52.2%) and 10 (14.5%) respectively. Conclusion: The prevalence of asymptomatic bacterirua among pregnant females was high (26.5%). The most common urinary isolates found among asymptomatic bacteriuria cases were E.coli.

Diagnostic and antibiotic stewardship lessons: an outpatient assessment of symptomatic reflex urinalysis ordering accuracy using an electronic best-practice alert.

It is not well known how reliably clinicians order reflex urinalysis to microscopy and culture (rUA-cx) for outpatient urinary tract infection (UTI) workup. Antibiotic appropriateness cannot be fully appreciated until the prevalence of UTIs and asymptomatic bacteriuria (ASB) are realized. This quality improvement study has two major aims, first to determine UTI symptom accuracy for rUA-cx ordering and second, to confirm UTI and ASB cases by integrating rUA-cx and cascaded urinalysis results. Antibiotic utilization and diagnostic coding were secondarily linked to UTIs and ASB. An electronic best-practice alert informed the ordering of two rUA-cx options: symptomatic- rUA-cx specifically for dysuria, frequency, urgency, costovertebral pain, suprapubic pain or fever versus non-specific-rUA-cx for vague complaints. UTI symptoms were verified by chart review. Confirmed UTI was defined as a significant culture with UTI symptoms and ASB as a significant culture without UTI symptoms. rUA-cx (2065) were prospectively collected over 6 months from female patients at risk for uncomplicated UTIs. Symptomatic-rUA-cx and non-specific-rUA-cx were associated with UTI symptoms for 53% (809/1527) and 20% (107/538), respectively. Overall, 44% (916/2065) of all rUA-cx had UTI symptoms. rUA-cx were overordered by a factor of 9 (2065/225) for every confirmed UTI. The UTI-to-ASB relative ratio was 2.6 (225/86). Regarding UTI-relevant antibiotics, 39% (214/553) were appropriately associated with UTI whereas only 22% (74/339) of inappropriate antibiotics were captured by the ASB definition, underestimating the problem 4-fold. UTI and ASB remain challenging to categorize despite a meticulous method that applied acceptable criteria.

Identification of novel factors associated with inappropriate treatment of asymptomatic bacteriuria in acute and long-term care

BackgroundChart reviews often fall short of determining what drove antibiotic treatment of asymptomatic bacteriuria (ASB). To overcome this shortcoming, we searched providers’ free-text for documentation of their decision-making and for misleading signs and symptoms that may trigger unnecessary treatment of ASB. MethodsWe reviewed a random sample of 10 positive urine cultures per month, per facility, from patients in acute or long-term care wards at 8 Veterans Affairs facilities. Cultures were classified as urinary tract infection (UTI) or ASB, and as treated or untreated. Charts were searched for 13 potentially misleading symptoms, and free-text documentation of providers’ decision-making was classified into 5 categories. We used generalized estimating equations logistic regression to identify factors associated with ASB treatment. ResultsOne hundred fifty-eight (27.5%) of 575 ASB cases were inappropriately treated with antibiotics. Significant factors associated with inappropriate treatment included: abdominal pain, falls, decreased urine output, urine characteristics, abnormal vital signs, laboratory values, and voiding issues. Providers prescribed an average of 1.4 antimicrobials to patients with ASB, with cephalosporins (41%) and fluoroquinolones (21%) being the most common classes prescribed. ConclusionsChart reviews of providers’ decision-making highlighted new factors associated with inappropriate ASB treatment. These findings can help design antibiotic stewardship interventions for ASB.

Asymptomatic and symptomatic bacteriuria in patients with type 2 diabetes

Aim: Asymptomatic bacteriuria (ASB) and symptomatic bacteriuria with antibiotic-resistant organisms are common in patients with type 2 diabetes. The aim was to study the prevalence, bacterial profile and antibiotic susceptibility pattern in ASB and symptomatic bacteriuria and the factors associated with Escherichia coli bacteriuria in type 2 diabetes. Materials and Methods: This was an observational case-control study done on 400 asymptomatic type 2 diabetes patients, 200 symptomatic urinary tract infection (UTI), and 200 nondiabetic controls. Various clinical, biochemical parameters and urine examination and culture were studied. Results: The prevalence of ASB and symptomatic bacteriuria in type 2 diabetes was 17.5% and 69%, respectively, and were significantly higher as compared to controls (10%). E. coli was present in 52.9% of ASB cases of type 2 diabetes and 70% of nondiabetic control ASB. E. coli (55%) was most commonly isolated in symptomatic bacteriuria. Majority of the Gram-negative bacteria isolates in ASB and symptomatic bacteriuria with type 2 diabetes and controls were sensitive to amikacin, imipenem, piperacillin/tazobactam, and nitrofurantoin. E. coli were more resistant to quinolones in ASB and symptomatic bacteriuria than controls. Most of the Gram-positive bacteria were sensitive to vancomycin, linezolid, and amoxiclav. The factors associated with E. coli bacteriuria in type 2 diabetes were female gender, long duration of diabetes, past history of symptomatic UTI, poor glycemic control, and renal function. Conclusions: E. coli remains the most common isolated microorganism in asymptomatic and symptomatic bacteriuria. E. coli were more resistant to quinolones in patients with type 2 diabetes.

73. Identification of Novel Factors Associated with Inappropriate Treatment of Asymptomatic Bacteriuria Treatment in Acute and Long-term Care

BackgroundInappropriate treatment of asymptomatic bacteriuria (ASB) is a major driver of antibiotic overuse. Demographic and laboratory factors associated with inappropriate antibiotic treatment include older age, pyuria, leukocytosis and dementia. To gain a deeper understanding of inappropriate ASB treatment, we performed an in-depth review of provider documentation capturing a broader range of misleading factors associated with ASB treatment.MethodsWe reviewed a random sample of 10 positive urine cultures per month per facility from acute or long-term care wards at eight Veteran’s Administration (VA) facilities from 2017-2019 (n=960). Trained chart reviewers classified cultures as UTI or ASB and as treated or untreated. Charts were searched specifically for mention of 8 categories of potentially misleading symptoms that often lead to overtreatment of ASB (e.g. “prior history of UTI”) (Figure legend). We also created a ‘suspected systemic inflammatory response syndrome (SIRS)’ category that included any mention of leukocytosis, tachycardia, tachypnea, subjective or low-grade fever, or hypothermia. Generalized estimating equations logistic regression was used for analysis. ResultsOur study included 575 cultures from patients that were primarily white (71%) males (94%) from acute medicine units (75.7%) with a mean age of 76. Twenty-eight percent (n=159) of ASB cases received antibiotics. In addition to the usual known predictors, multiple new misleading symptoms were found to be associated with ASB treatment (Table). Novel, independent predictors of ASB treatment included behavioral issues, such as falls or fatigue (odds ratio (OR): 1.8; 95% CI: 1.05-3.07), urine characteristics, such as cloudy or odorous urine (OR: 1.41; 95% CI: 1.13-1.75), voiding issues (OR: 1.86; 95% CI: 1.43-2.41), and a single, free text mention of a SIRS criteria (OR: 1.63; 95% CI: 1.16-2.3). P-values extracted from multivariate regression model (ASB-asymptomatic bacteriuria; NS-not significant; SIRS- systemic inflammatory response syndrome). The following signs or symptoms compose each category: abnormal laboratory findings: acute kidney injury, abnormal creatinine, leukocytosis, pyuria/positive urinalysis, hyperglycemia; abnormal vital sign: bradycardia, tachycardia, atrial fibrillation, hypotension, hypertension, hypoxia, tachypnea, subjective fever or low-grade fever, syncope; behavior issues: falls, confusion lethargy, fatigue, weakness; nonspecific signs or symptoms: nonspecific gastrointestinal, genitourinary, neurological symptoms; voiding issues: decreased urine output, urinary retention, urinary incontinence; urine characteristics: change in color, foul smell, cloudy urine, sediment; SIRS: ordinal variable characterizing if 1 or ≥ 2 of the following were documented by the provider: leukocytosis, tachycardia, tachypnea, subjective or low-grade fever, hypothermia. ConclusionOur in-depth chart review, with attention to misleading symptoms and any documentation of the provider thought process, highlights new factors associated with inappropriate ASB treatment. Patients with even a single SIRS criteria are at risk for unnecessary treatment of ASB; this finding can help design antibiotic stewardship interventions.Disclosures Barbara Trautner, MD, PhD, Genentech (Consultant, Scientific Research Study Investigator)

Urinary infection in the elderly

IntroductionUrinary tract infections (UTIs) are one of the most frequent infections. In the elderly, they have multiple comorbidities. The objective of this work is to describe the clinical and microbiological epidemiology of elderly persons admitted for UTIs and to evaluate the suitability of empirical treatments and their implications regarding mortality. Material and methodsAn observational study was conducted during 2013–2015 in 4 public hospitals, with patients older than 65 years who were admitted to the Internal Medicine service with a microbiological diagnosis of UTI. Cases of asymptomatic bacteriuria were excluded. In-hospital mortality was analyzed. Univariate analysis and multivariate analysis was carried out. ResultsA total of 349 episodes were selected, with a mean age of 82±11 years, 51% female. Mortality was 10.3% and was associated with age, dementia and sepsis and septic shock (p<0.05). The most frequent organisms were Escherichia coli (E. coli) (53.6%), Klebsiella spp. (8.7%) and Enterococcus spp. (6.6%). E. coli and Klebsiella spp. with extended-spectrum beta-lactamases (13% of the total isolated) were associated with the previous use of antibiotics, community care treatment and a permanent urinary catheter (p<0.05). The empirical treatment was adequate only in 73.6% of cases. As these treatments were associated with higher mortality, they were not considered adequate. ConclusionsIn the elderly, UTIs show a high mortality. Empirical treatment is often inadequate and may be associated with increased mortality.

Infección urinaria en el anciano

IntroductionUrinary tract infections (UTIs) are one of the most frequent infections. In the elderly, they have multiple comorbidities. The objective of this work is to describe the clinical and microbiological epidemiology of elderly persons admitted for UTIs and to evaluate the suitability of empirical treatments and their implications regarding mortality. Material and methodsAn observational study was conducted during 2013-2015 in 4public hospitals, with patients older than 65 years who were admitted to the Internal Medicine service with a microbiological diagnosis of UTI. Cases of asymptomatic bacteriuria were excluded. In-hospital mortality was analyzed. Univariate analysis and multivariate analysis was carried out. ResultsA total of 349 episodes were selected, with a mean age of 82 ± 11 years, 51% female. Mortality was 10.3% and was associated with age, dementia and sepsis and septic shock (P<.05). The most frequent organisms were Escherichia coli(E. coli) (53.6%), Klebsiella spp. (8.7%) and Enterococcus spp. (6.6%). E. coli and Klebsiella spp. with extended-spectrum beta-lactamases (13% of the total isolated) were associated with the previous use of antibiotics, community care treatment and a permanent urinary catheter (P<.05). The empirical treatment was adequate only in 73.6% of cases. As these treatments were associated with higher mortality, they were not considered adequate. ConclusionsIn the elderly, UTIs show a high mortality. Empirical treatment is often inadequate and may be associated with increased mortality.

Prevalence of urodynamic changes with risk for upper urinary tract damage in neuroschistosomiasis patients.

This study aimed to identify the prevalence of urodynamic changes with an associated risk of developing upper urinary tract damage in neuroschistosomiasis patients. A prospective study was conducted, wherein68 patients were admitted for analysis of urodynamics, urea and creatinine levels, and uroculture. Blood test results did not indicate kidney failure. There were cases of asymptomatic bacteriuria. Common symptoms were frequent nocturia and detrusor overactivity. Results of low compliance and low cystometric capacity were both statistically significant (p = 0.001 and p = 0.002, respectively). A high prevalence of negative urodynamic changes were found in neuroschistosomiasis patients.

A case study of symptomatic urinary tract infection by Shigella sonnei in adult female and a short review on drug-resistant Shigella species

Shigella species belong to family Enterobacteriaceae and are causative agents of bacillary dysentery. The whole spectrum of disease caused by Shigella species is called Shigellosis. Shigella has four major subgroups: Shigella dysenteriae, Shigella flexneri, Shigella boydii, and Shigella sonnei. S. sonnei causes the mildest form of bacillary dysentery, and in many cases, it causes only mild diarrhea. It is the most common Shigellosis in developed countries. There are few reported cases of asymptomatic bacteriuria due to S. sonnei both in adults and pediatric patients. Few cases of symptomatic urinary tract infection (UTI) are also reported. In pediatric patients, the common risk factor for UTI is found to be vesicoureteric reflux, especially in females. Recent studies done in various countries show an alarming increase in resistance of Shigella species to commonly used antibiotics such as chloramphenicol, ampicillin, co-trimoxazole, nalidixic acid, fluoroquinolones, macrolides, and cephalosporins. Many outbreaks of Shigellosis by multidrug-resistant (MDR) strains have also been reported. Shigella rarely causes extraintestinal manifestations such as hemolytic uremic syndrome, hyponatremia, reactive arthritis, altered neurologic state, bacteremia, UTI, and vulvovaginitis. UTI is a rare complication of Shigella infection. Here, we report a case of UTI due to S. sonnei in an adult female with diabetes mellitus (DM). We have also done a short review of increasing antibiotic resistance among Shigella species. The Institutional Ethics Committee approval was obtained to publish this case study. A 64-year female presented to an outpatient clinic with symptoms of UTI. Urine culture was done by the semi-quantitative method in blood agar plate and MacConkey agar. A Gram-negative bacilli were isolated with a significant colony count of >100,000 cfu/ml. Antibiotic sensitivity was done by both disc diffusion method and minimum inhibitory concentration. Stool culture was also done after 4 days. In this case study, S. sonnei was isolated from urine, but stool culture done after 4 days of treatment with antibiotic was negative. The patient was newly diagnosed with type 2 DM. Hence, DM could be a risk factor for S. sonnei UTI in the elderly. Taking into consideration the emergence of antibiotic resistance among S. sonnei isolates, knowledge of antibiotic sensitivity pattern is crucial in the treatment of such infections. In our study, the isolate was not MDR. It was sensitive to ampicillin, cefixime, cefotaxime, ciprofloxacin, nitrofurantoin, and norfloxacin and azithromycin and resistant to co-trimoxazole and nalidixic acid.

Infections in Older Adults: A Case-Based Discussion Series Emphasizing Antibiotic Stewardship.

Compared with younger populations, adults 65 years and older are more likely to suffer infection-related morbidity and mortality, experience antibiotic-related adverse events, and acquire multidrug-resistant organisms. We developed a series of case-based discussions that stressed antibiotic stewardship while addressing management of common infections in older adults. Five 1-hour case-based discussions address recognition, diagnosis, and management of infections common in older adults, including those living in long-term care settings: urinary tract infections, upper respiratory tract infections, lower respiratory tract infections, skin and soft tissue infections, and Clostridium difficile infection. The education was implemented at the skilled nursing centers at 15 Veterans Affairs medical centers. Participants from an array of disciplines completed an educational evaluation for each session as well as a pre- and postcourse knowledge assessment. The number of respondents to the educational evaluation administered following each session ranged from 68 to 108. Learners agreed that each session met its learning objectives (4.80-4.89 on a 5-point Likert scale, 5 = strongly agree) and that they were likely to make changes (2.50-2.89 on a 3-point scale, 3 = highly likely to make changes). The average score on the five-question knowledge assessment increased from 3.6 (72%) to 3.9 (78%, p = .06). By stressing recognition of atypical signs and symptoms of infection in older adults, diagnostic tests, and antibiotic stewardship, this series of five case-based discussions enhanced clinical training of learners from several disciplines.

Prevalence of asymptomatic bacteriuria among antenatal women and its effects on maternal and perinatal outcome in northern Andhra Pradesh population

Background: The pregnant women are more commonly affected with asymptomatic bacteriuria (ASB) than non-pregnant women and its progression could lead to adverse maternal and perinatal outcomes. The study was designed with an aim to know the prevalence of ASB and its effects on maternal and perinatal outcome.Methods: In this prospective study, 300 antenatal women attending Anil Neerukonda Hospital were screened for ASB. Urine culture was performed using standardized Kirby-Bauer disc diffusion method on blood agar, Mac Conkey’s agar for antibiotic sensitivity testing. The screened antenatal women were divided into two subgroups viz. asymptomatic bacteriuria positive (Group I) and asymptomatic bacteriuria negative (Group II) depending on the culture study and were followed till delivery for maternal and perinatal outcomes.Results: The prevalence of ASB was 11.33%. Out of 34 cases of ASB positive, 8 cases (23.5%) were delivered with birth weight &lt;2500 grams as compared to 11 cases (4.1%) in unexposed cases (RR 5.68, 95% CI; 2.46-13.15; p&lt;0.05). Preterm low birth was noticed in 5 (14.7%) cases of ASB positive pregnant women with compared to unexposed cases (RR 1.5, 95% CI; 0.61-3.65, p=0.36). Regarding maternal outcomes, premature labour was observed in 8 cases (23.5%) of ASB exposed women whereas 22 (8.3%) in non-exposed cases (RR 2.84, 95% CI; 1.37-5.88, p=0.004). A significant number of women have developed hypertension (17.6%) and preeclampsia (8.8%) in ASB positive cases as compared to ASB negative cases (4.9% and 2.3% respectively).Conclusions: The prevalence of ASB was 11.33% in the present study. As one third of the cases were identified in early and late trimesters, regular and trimester wise screening need to be incorporated in routine antenatal screening for safe motherhood and new born health.

Asymptomatic bacteriuria and its associated factors in type II diabetes mellitus

Background: With the dawn of modern era the diabetes epidemic has spread over continents affecting the developed and the developing nations alike. Asymptomatic bacteriuria which is quite prevalent in the diabetic population is associated with increased diabetic complications and thereby increased morbidity. Thus, the aim of this study was to assess the proportion of cases with asymptomatic bacteriuria (ASB) among type II diabetes mellitus patients as compared to non-diabetic healthy controls and studying the factors associated with ASB.Methods: 93 eligible type II diabetes mellitus cases without genitourinary symptoms or abnormalities along with 93 non-diabetic healthy controls were recruited. Mid-stream urine was collected after taking informed consent and each sample tested using the dipstick, microscopy and culture techniques. Isolates were identified using standard biochemical tests.Results: Prevalence of ASB in our study was found to be 34.4% among cases of type II diabetes mellitus while it was 6.45% among non-diabetic healthy controls. Amongst the diabetics with ASB 71.9 % were females and 28.13 % were males. E. Coli was isolated in 21 subjects among diabetic cases (22.58%) and in 5 subjects among non-diabetic healthy controls (5.38%). Fasting blood sugar (FBS) in diabetic cases group was 151.08 ± 48.16 and in control group was found to be 98.57 ± 25.95 (p&lt;0.001). Mean duration of patients with DM who had ASB (32) was 8.46 ± 4.14 years and those who were culture negative was 4.59 ± 4.2 years (p &lt; 0.05). 24 subjects (75%) out of 32 diabetic ASB cases had glycosuria compared to 27 subjects (44.26%) out of 61 culture negative cases (p &lt; 0.05). 9 out of 32 (28.13%) diabetic ASB subjects had proteinuria compared to 4 out of 61 (6.56%) culture negative cases (p &lt; 0.05).Conclusions: Overall prevalence of ASB was significantly more in diabetic population as compared to non-diabetic healthy controls (34.4% vs 6.45%). Females have an increased likelihood of developing ASB as compared to males. E. Coli was the most common pathogen isolated in ASB cases. Longer duration of diabetes and poor glycemic control are independent predictors for the development of ASB. The risk of ASB is also significantly increased in those with glycosuria and proteinuria.

Routine Urine Testing at the Spinal Cord Injury Annual Evaluation Leads to Unnecessary Antibiotic Use: A Pilot Study and Future Directions

ObjectivesTo measure the prevalence of asymptomatic bacteriuria (ASB) in persons with spinal cord injury (SCI) at the time of their annual examination and to examine the effect on urine testing during the annual examination on subsequent antibiotic use. DesignRetrospective cohort study. SettingA major SCI center. ParticipantsVeterans (N=393) with SCI seen for an outpatient annual evaluation in 2012 or 2013. InterventionsNot applicable. Main Outcome MeasuresAntibiotic use for bacteriuria within 7 days of the annual evaluation encounter. ResultsThere were 327 clinic visits that met inclusion criteria; of these 327 veterans, 249 had a urine culture performed. A total of 171 urine cultures (69%) were positive for bacteria, of which 22 (13%) represented urinary tract infection (UTI) cases and 149 (87%) were ASB cases. More than a third of the ASB cases (n=53 [36%]) were treated with antibiotics. None of the 78 visits with negative urine cultures received antibiotics to treat the UTI; thus, a positive urine culture alone was associated with antibiotic use (P<.01). Factors predicting antibiotic use were higher age, nitrite presence on urinalysis, and urease-producing organism on culture media. When comparing bladder management strategies, indwelling catheterization was found to be associated with higher levels of pyuria and hematuria than did spontaneous voiding or intermittent catheterization (P<.01). ConclusionsTwo-thirds of the urine cultures of persons with SCI presenting for their annual examination were positive. Most of the positive cultures represented ASB cases, and more than a third of these were treated with antibiotics. A better understanding of the mandate for urine testing at the annual examination and the outcomes of this practice is an important first step in developing antibiotic stewardship for UTI in persons with SCI.

Prevalence, risk factors and causative organisms of asymptomatic bacteriuria in pregnancy

Background: Asymptomatic bacteriuria (ASB) is a relatively common condition occurring due to the morphological and physiological changes in the genitourinary tract during pregnancy. If left untreated, it may lead to acute pyelonephritis and adverse fetal and maternal outcomes. The objective was to determine prevalence, risk factors and etiological agents with susceptibility for ASB among pregnant women attending an antenatal clinic at a tertiary care hospital, Odisha, India.Methods: A prospective study with 200 pregnant women was conducted, over a period of 4 months, starting from 1st April 2017 to 31st July 2017. The mid- stream clean catch urine specimen was collected and processed in all the cases and other data were collected from the questionnaire given to them. The isolates from all the cases of ASB were identified and antimicrobial susceptibility was tested by Kirby- Bauer disc diffusion method and interpreted.Results: Prevalence of ASB in our study was 25.3%, with maximum prevalence among age group 21-30 yrs, during 3rd trimester, among multigravidae. Previous history of urinary tract infection (UTI), anaemia and diabetes have significant association with ASB. Klebsiella spp. was the predominant isolate in this study followed by Escherichia coli. Nitrofurantoin and Cefixime are safe and effective antibiotics against urinary pathogens in pregnancy.Conclusions: Undiagnosed and untreated asymptomatic bacteriuria is associated with complications during pregnancy. Hence routine screening of antenatal women for ASB during all trimesters must be considered for preventing the adverse maternal and foetal outcomes particularly with known risk factors like increasing age, multiparity and previous history of UTI.

Urethral (indwelling or intermittent) or suprapubic routes for short-term catheterisation in hospitalised adults.

Indwelling urethral catheters are often used for bladder drainage in hospital. Urinary tract infection is the most common hospital-acquired infection, and a common complication of urinary catheterisation. Pain, ease of use and quality of life are important to consider, as well as formal economic analysis. Suprapubic catheterisation can also result in bowel perforation and death. To determine the advantages and disadvantages of alternative routes of short-term bladder catheterisation in adults in terms of infection, adverse events, replacement, duration of use, participant satisfaction and cost effectiveness. For the purpose of this review, we define 'short-term' as intended duration of catheterisation for 14 days or less. We searched the Cochrane Incontinence Group Specialised Register, which contains trials identified from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, MEDLINE in process, ClinicalTrials.gov, WHO ICTRP and handsearching of journals and conference proceedings (searched 26 February 2015), CINAHL (searched 27 January 2015) and the reference lists of relevant articles. We included all randomised and quasi-randomised trials comparing different routes of catheterisation for short-term use in hospitalised adults. At least two review authors extracted data and performed 'Risk of bias' assessment of the included trials. We sought clarification from the trialists if further information was required. In this systematic review, we included 42 trials.Twenty-five trials compared indwelling urethral and suprapubic catheterisation. There was insufficient evidence for symptomatic urinary tract infection (risk ratio (RR) 1.01, 95% confidence interval (CI) 0.61 to 1.69; 5 trials, 575 participants; very low-quality evidence). Participants with indwelling catheters had more cases of asymptomatic bacteriuria (RR 2.25, 95% CI 1.63 to 3.10; 19 trials, 1894 participants; very low quality evidence) and more participants reported pain (RR 5.62, 95% CI 3.31 to 9.55; 4 trials, 535 participants; low-quality evidence). Duration of catheterisation was shorter in the indwelling urethral catheter group (MD -1.73, 95% CI -2.42 to -1.05; 2 trials, 274 participants).Fourteen trials compared indwelling urethral catheterisation with intermittent catheterisation. Two trials had data for symptomatic UTI which were suitable for meta-analysis. Due to evidence of significant clinical and statistical heterogeneity, we did not pool the results, which were inconclusive and the quality of evidence was very low. The main source of heterogeneity was the reason for hospitalisation as Hakvoort and colleagues recruited participants undergoing urogenital surgery; whereas in the trial conducted by Tang and colleagues elderly women in geriatric rehabilitation ward were recruited. The evidence was also inconclusive for asymptomatic bacteriuria (RR 1.04; 95% CI 0.85 to 1.28; 13 trials, 1333 participants; very low quality evidence). Almost three times as many people developed acute urinary retention with the intermittent catheter (16% with urethral versus 45% with intermittent); RR 0.45, 95% CI 0.22 to 0.91; 4 trials, 384 participants.Three trials compared intermittent catheterisation with suprapubic catheterisation, with only female participants. The evidence was inconclusive for symptomatic urinary tract infection, asymptomatic bacteriuria, pain or cost.None of the trials reported the following critical outcomes: quality of life; ease of use, and cost utility analysis. Suprapubic catheters reduced the number of participants with asymptomatic bacteriuria, recatheterisation and pain compared with indwelling urethral. The evidence for symptomatic urinary tract infection was inconclusive.For indwelling versus intermittent urethral catheterisation, the evidence was inconclusive for symptomatic urinary tract infection and asymptomatic bacteriuria. No trials reported pain.The evidence was inconclusive for suprapubic versus intermittent urethral catheterisation. Trials should use a standardised definition for symptomatic urinary tract infection. Further adequately-powered trials comparing all catheters are required, particularly suprapubic and intermittent urethral catheterisation.