Outpatient Urinary Tract Infections Research Articles

1450. Risk Factors for Antibiotic Resistance of Escherichia coli Urinary Isolates in Outpatients

BackgroundAntibiotic-resistant E. coli infections represent a major cause of morbidity and mortality, and pose a challenge to antibiotic stewardship. Patient age has been suggested as a key determinant of resistance patterns in studies based in the United States and Europe, although local antibiotic use patterns may affect this relationship. We analyzed results from clinical antibiotic susceptibility tests performed at a large reference laboratory to further examine the association of age with E. coli urinary tract resistance patterns in WA State.MethodsWe analyzed 5 years of E. coli antibiotic susceptibility data for outpatient urinary tract infections in WA State from a national clinical reference laboratory. We included only the first isolate recorded for each patient and calculated crude rates of resistance to antibiotics for the age groups of 50 years. In a multivariate logistic model, we tested the effect of patient age, year of antimicrobial susceptibility test submission, and sex on antibiotic resistance.ResultsUnivariate analyses indicated that resistance rates differed significantly across patient age groups for ciprofloxacin and nitrofurantoin. Among females, resistance rates also differed significantly across patients age groups for amoxicillin-clavulanate and gentamicin. Logistic regression using data from male patients found the odds of resistance to be significantly greater in older individuals for ciprofloxacin (OR 2.59) and lower in older individuals for amoxicillin-clavulanate (OR 0.56). For females, logistic regression found the odds of resistance to be significantly greater for older individuals for amoxicillin-clavulanate (OR 1.43), ciprofloxacin (OR 3.04), ceftriaxone (OR 2.58), nitrofurantoin (OR 2.20), and gentamicin (OR 1.62).ConclusionIn WA State, the distribution of antibiotic resistance in E. coli urinary isolates varies with age, sex and the antibiotic of interest. Greater and more timely use of databases of susceptibility testing of clinical isolates from outpatient settings can allow for the creation of age-specific antibiograms to guide and improve stewardship. Disclosures All authors: No reported disclosures.

1107. Impact of Routine Education and Data Feedback on the Durability of an Antimicrobial Stewardship Intervention for Outpatient Urinary Tract Infections

BackgroundAchieving lasting, sustainable effects in outpatient AS interventions has been a challenge for many programs. Our group observed an initial benefit of an outpatient AS intervention focused on diagnosis and management of urinary tract infections (UTIs). However, prescribing habits trended back toward baseline over time. This study aimed to evaluate the impact of routine education and comparative data feedback on the durability of an outpatient AS intervention for UTIs.MethodsWe conducted a prospective quasi-experimental study at one primary care (PC) and one urgent care (UC) clinic to evaluate the durability of an outpatient AS intervention implemented in August 2017 and November 2017, respectively. Clinicians who treated adult patients with a diagnosis of acute UTI at either clinic participated in the study. The initial intervention (phase 1) included development of clinic-specific antibiograms and UTI diagnosis and treatment guidelines. Approximately 12 months after the initial intervention, routine education along with clinic- and comparative provider-specific feedback reports were emailed to clinicians at regular intervals (phase 2). The primary outcome was percent of encounters in which first- or second-line antibiotics were prescribed. Pre- and post-intervention phase and trend changes were assessed using an interrupted time-series approach.ResultsData were collected on 792 and 3,720 UTI encounters at PC and UC, respectively. In the 12 months after the initial intervention, rates of guideline concordance were 73% at PC and 57% at UC (Figures 1 and 2). After routine data feedback was provided for approximately 7 months at PC and 5 months at UC, rates of guideline concordance remained relatively stable at 75% for PC and 61% at UC. An initial 37% relative reduction in fluoroquinolone (FQ) use was observed during phase 1 which was further reduced by an additional 18% during phase 2.ConclusionRoutine provision of clinic-specific feedback and peer comparisons sustained rates of guideline-concordant prescribing at two outpatient clinics. This intervention required significant resources for data analysis and delivery, but it was successful in decreasing rates of FQ prescribing and maintaining clinician engagement. Disclosures All authors: No reported disclosures.

Outpatient Urinary Tract Infections in an Era of Virtual Healthcare: Trends From 2008 to 2017.

Urinary tract infections (UTIs) occur commonly, but recent data on UTI rates are scarce. It is unknown how the growth of virtual healthcare delivery affects outpatient UTI management and trends in the United States. From 1 January 2008 to 31 December 2017, UTIs from outpatient settings (office, emergency, and virtual visits) were identified from electronic health records at Kaiser Permanente Southern California using multiple UTI definitions. Annual rates estimated by Poisson regression were stratified by sex, care setting, age, and race/ethnicity. Annual trends were estimated by linear or piecewise Poisson regression. UTIs occurred in 1 065 955 individuals. Rates per 1000 person-years were 53.7 (95% confidence interval [CI], 50.6-57.0) by diagnosis code with antibiotic and 25.8 (95% CI, 24.7-26.9) by positive culture. Compared to office and emergency visits, UTIs were increasingly diagnosed in virtual visits, where rates by diagnosis code with antibiotic increased annually by 21.2% (95% CI, 16.5%-26.2%) in females and 29.3% (95% CI, 23.7%-35.3%) in males. Only 32% of virtual care diagnoses had a culture order. Overall, UTI rates were highest and increased the most in older adults. Rates were also higher in Hispanic and white females and black and white males. Outpatient UTI rates increased from 2008 to 2017, especially in virtual care and among older adults. Virtual care is important for expanding access to health services, but strategies are needed in all outpatient care settings to ensure accurate UTI diagnosis and reduce inappropriate antibiotic treatment.

Sodium-Glucose Cotransporter-2 Inhibitors and the Risk for Severe Urinary Tract Infections: A Population-Based Cohort Study.

Prior studies evaluating risk for severe urinary tract infections (UTIs) with sodium-glucose cotransporter-2 (SGLT-2) inhibitors have reported conflicting findings. To assess whether patients initiating use of SGLT-2 inhibitors were at increased risk for severe UTI events compared with those initiating use of dipeptidyl peptidase-4 (DPP-4) inhibitors or glucagon-like peptide-1 receptor (GLP-1) agonists. Population-based cohort study. 2 large, U.S.-based databases of commercial claims (March 2013 to September 2015). Within each database, 2 cohorts were created and matched 1:1 on propensity score. Patients were aged 18 years or older, had type 2 diabetes mellitus, and were initiating use of SGLT-2 inhibitors versus DPP-4 inhibitors (cohort 1) or GLP-1 agonists (cohort 2). The primary outcome was a severe UTI event, defined as a hospitalization for primary UTI, sepsis with UTI, or pyelonephritis; the secondary outcome was outpatient UTI treated with antibiotics. Hazard ratios (HRs) were estimated in each propensity score-matched cohort, with adjustment for more than 90 baseline characteristics. After 1:1 matching on propensity score, 123752 patients were identified in cohort 1 and 111978 in cohort 2 in the 2 databases. In cohort 1, persons newly receiving SGLT-2 inhibitors had 61 severe UTI events (incidence rate [IR] per 1000 person-years, 1.76), compared with 57 events in the DPP-4 inhibitor group (IR, 1.77) (HR, 0.98 [95% CI, 0.68 to 1.41]). In cohort 2, those receiving SGLT-2 inhibitors had 73 events (IR, 2.15), compared with 87 events in the GLP-1 agonist group (IR, 2.96) (HR, 0.72 [CI, 0.53 to 0.99]). Findings were robust across sensitivity analyses; within several subgroups of age, sex, and frailty; and for canagliflozin and dapagliflozin individually. In addition, SGLT-2 inhibitors were not associated with increased risk for outpatient UTIs (cohort 1: HR, 0.96 [CI, 0.89 to 1.04]; cohort 2: HR, 0.91 [CI, 0.84 to 0.99]). Generalizability of the study findings may be limited to patients with commercial insurance. In a large cohort of patients seen in routine clinical practice, risk for severe and nonsevere UTI events among those initiating SGLT-2 inhibitor therapy was similar to that among patients initiating treatment with other second-line antidiabetic medications. Brigham and Women's Hospital, Division of Pharmacoepidemiology and Pharmacoeconomics.

Resistance Trends and Epidemiology of Citrobacter-Enterobacter-Serratia in Urinary Tract Infections of Inpatients and Outpatients (RECESUTI): A 10-Year Survey.

Background and objectives: Urinary tract infections (UTIs) are the third most common infections in humans, representing a significant factor of morbidity, both among outpatients and inpatients. The pathogenic role of Citrobacter, Enterobacter, and Serratia species (CES bacteria) has been described in UTIs. CES bacteria present a therapeutic challenge due to the various intrinsic and acquired resistance mechanisms they possess. Materials and Methods: The aim of this study was to assess and compare the resistance trends and epidemiology of CES pathogens in UTIs (RECESUTI) in inpatients and outpatients during a 10-year study period. To evaluate the resistance trends of isolated strains, several antibiotics were chosen as indicator drugs based on local utilization data. 578 CES isolates were obtained from inpatients and 554 from outpatients, representing 2.57 ± 0.41% of all positive urine samples for outpatients and 3.02 ± 0.40% for inpatients. E. cloacae was the most prevalent species. Results: The ratio of resistant strains to most of the indicator drugs was higher in the inpatient group and lower in the second half of the study period. ESBL-producing isolates were detected in 0–9.75% from outpatient and 0–29.09% from inpatient samples. Conclusions: Resistance developments of CES bacteria, coupled with their intrinsic non-susceptibility to several antibiotics, severely limits the number of therapeutic alternatives, especially for outpatients.

Age-Specific Cutoffs of the Sysmex UF-1000i Automated Urine Analyzer for Rapid Screening of Urinary Tract Infections in Outpatients.

We investigated the usefulness of age-specific cutoffs for screening of urinary tract infections (UTIs) in Korean outpatients, using the automated urine analyzer UF-1000i (Sysmex, Kobe, Japan). We retrospectively reviewed outpatient medical records. Urine samples of 7,443 outpatients from January 2010 to December 2017 were analyzed using urine culture and UF-1000i. ROC curves were calculated for each UF-1000i parameter based on the culture results. There were 1,398 culture positive samples, 5,774 culture negative samples, and 271 contaminated samples. UF-1000i had an area under the curve of ≥0.9 in outpatients >15 years. The appropriate cutoffs, which are the sum of bacterial (B-A-C) and white blood cell (WBC) counts, were 297.10/µL (15–24 years), 395.65/µL (25–44 years), 135.65/µL (45–64 years), 67.95/µL (65–74 years), and 96.5/µL (≥75 years). B-A-C and WBC counts differed among the three most frequently identified bacteria (Escherichia coli, Klebsiella pneumoniae, and Enterococcus faecalis). The UF-1000i system is useful for applying age-specific cutoffs to screen for UTIs, thereby preventing antibiotic abuse and reducing antibiotic resistance. Future studies can explore how its B-A-C and WBC counts can facilitate selection of empirical antibiotics by distinguishing between gram-positive and gram-negative bacteria.

Correlating Urinary Tract Infection with Patients’ Presenting Symptoms and Bacterial Isolation from Urine in Uyo, Nigeria

Background: In clinical practice, diagnosis of urinary tract infection (UTI) ideally involves the presence of symptoms and a positive urine culture results. However, due to lack of laboratory facility and where present, delays in getting laboratory result encountered by attending out-patient Physicians, diagnosis are made from presenting symptoms in patients. Empirical treatments are commenced with expectation of positive outcome. Objectives: The aim of this study was to correlate Urinary tract infection with presenting symptoms in patients and laboratory culture results from mid-stream urine samples in Uyo, Nigeria. Materials and Methods: This six months descriptive cross sectional study was carried out in the outpatient Department of the University of Uyo Teaching Hospital in Uyo. Data was obtained through questionnaire administered on 370 consenting outpatients and laboratory culture results from collected midstream urine were analyzed using SPSS software (version 20.0). The predisposing risk factors in these patient were also assessed. The midstream urine samples from the subjects were standardly processed. Cultured urine samples that yielded Gram negative uropathogens were further identified using Microbact 24E (Oxoid, UK), while those that yielded Gram positive uropathogens were identified by the appropriate standard procedures. Results: The presenting symptoms were; discomfort when urinating, urge incontinence (7.6%), frequent urination (11.9%), and cloudy urine with foul smell (8.1%), malaise (23.8%), fever (23.5%), back/flank pain (3.8%) and hematuria (4.6%) (P<0.001). The attendant risks factors assessed were age, gender, cleaning method after urination/defecation, contraceptive use, diabetes, past history of UTI and recent catheter use (P<0.05). Female outpatients had more laboratory confirmed UTI (25.9%) than male outpatients (11.5%). Also revealed is the fact that there is higher prevalence of UTI in female outpatients within the reproductive age group of 28-37 years (43.8%). Conclusion: In this study, less than 30% of female patients with presenting symptoms of UTI had positive urine culture test result while only about 12% of males with these symptoms are culture positive for UTI in Uyo, Akwa Ibom State, Nigeria.

1527. The Prevalence of Enterobacteriaceae (ENT) Resistant to All Major Classes of Oral Antibiotics from Outpatient Urine Cultures in the United States and Effect on Clinical Outcomes

BackgroundOver 99% of all outpatient urinary tract infections (UTI) in the United States are treated with either a quinolone, β-lactam, trimethoprim-sulfamethoxazole (T/S) or nitrofurantoin (NFH). Resistance to all classes of antibiotics is now reported in the US, making the selection of empiric oral therapy increasingly unlikely to cover the offending uropathogen.MethodsWe queried the BD Insights Research Database (Franklin Lakes, NJ) to evaluate ambulatory antibiotic fill history for patients from 15 US institutions with an ambulatory urine culture positive for ≥103 CFU/mL of an ENT. Patients who filled a prescription for an oral antibiotic were further categorized into those with a urine culture positive for a susceptible or non-susceptible (NS) pathogen. ESBL positivity was presumed if the isolate was NS to extended spectrum cephalosporins. Outcome was assessed using two surrogate endpoints: hospital admission, or a follow-up oral antibiotic within 28 days of initial antibiotic fill. Urine 30 day nonduplicate ambulatory three drug resistance rates in Q2 2017 were determined by zip code for 379 facilities.Results48/5,587 (0.9%) episodes of UTI with an outpatient urine culture had an Enterobacteriaceae that was resistant to quinolones, T/S, and NFH, and was ESBL-positive. Of those with at least three-drug class resistance, the hospital admission rate was 28%.28-Day Prescription Fill28-Day Readmission N (%)FailuresFail % P-Value N (%)FailuresFail % P–ValueOverall5,5871250225,3953797Pan-susceptible1,771 (32)287160.00011,627 (30)12480.00013-4 Class Resistancea197 (4)5528184 (3)5128 aAll resistant to quinolones, T/S, and β-lactams; four class also includes resistance to NFH.Figure:Geographic prevalence of three drug class resistance (quinolones, β-lactam, T/S) among Enterobacteriaceae causing UTI in the outpatient setting.ConclusionMulticlass resistance to existing oral antibiotics is prevalent throughout the United States in patients for whom an outpatient urine culture is available, with 1% of organisms resistant to all commonly available oral classes. Multidrug resistance in patients with an outpatient urine culture is associated with a significantly increased risk of treatment failure and subsequent hospitalization.Disclosures M. Dunne, Iterum Therapeutics: Employee and Shareholder, Salary. V. Gupta, Melinta Therapeutics, Inc.: Research Contractor, Research support. S. Aronin, Iterum Therapeutics: Employee and Shareholder, Salary. S. Puttagunta, Iterum Therapeutics: Employee and Shareholder, Salary.

Antimicrobial resistance of Escherichia coli isolates from outpatient urinary tract infections in women in six European countries including Russia

In the Northern Dimension Antibiotic Resistance Study (NoDARS), Finland, Germany, Latvia, Poland, Russia and Sweden collected urine samples from outpatient women (aged 18-65years) with symptoms of uncomplicated urinary tract infection (UTI) to investigate the levels of antimicrobial resistance (AMR) among Escherichia coli isolates. A total of 775 E. coli isolates from 1280 clinical urine samples were collected from October 2015 to January 2017. Antimicrobial susceptibility testing was performed and the results were interpreted according to European Committee on Antimicrobial Susceptibility Testing (EUCAST) criteria. Overall AMR rates to the commonly used antibiotics nitrofurantoin, fosfomycin and mecillinam (except for Germany that was missing a result for mecillinam) were 1.2%, 1.3% and 4.1%, respectively. The highest overall resistance rates were determined for ampicillin (39.6%), trimethoprim (23.8%), trimethoprim/sulfamethoxazole (22.4%), amoxicillin/clavulanic acid (16.7%) and ciprofloxacin (15.1%), varying significantly between countries. The rate of extended-spectrum β-lactamase (ESBL) production was 8.7%. None of the isolates showed resistance to meropenem. In most cases, low AMR rates were detected against the first-line antibiotics recommended in national UTI treatment guidelines, giving support to their future use. These results also support the European Association of Urology guidelines stating that nitrofurantoin, fosfomycin and mecillinam are viable treatment options for uncomplicated UTI.

Risk analysis of antimicrobial resistance in outpatient urinary tract infections of young healthy adults.

Most studies addressing community-acquired urinary tract infections (UTIs) pertain to mixed cohorts, in which young healthy adults are under-represented. We aimed to dissect the intricate interrelation between exposures and subsequent antimicrobial resistance (AMR) patterns in a unique setting of young healthy adults, allowing further guidance in this group. We carried out a retrospective cross-sectional study of all Enterobacteriaceae-associated outpatient UTIs during 2014-16 in soldiers, representing the young fit population in Israel. Electronic medical records were reviewed for demographic and clinical data, antimicrobial exposures and prescriptions. Risk factors for AMR were analysed by multivariate logistic regression. Of 1207 cases, 1144 (94.8%) were females, with a median age of 20.2 years. Escherichia coli was the predominant species (83.2%). Only 686 (56.8%) isolates were fully susceptible. AMR rates were as follows: trimethoprim/sulfamethoxazole, 19.6%; oral cephalosporins, 9.7%-16.7%; amoxicillin/clavulanate, 12.1%; ciprofloxacin, 11.1%; and nitrofurantoin, 12.6%. Predictors of AMR were recurrent UTIs, past-year hospitalization, male gender and non E. coli strains. Antimicrobials prescribed >6 months preceding the culprit infection were not related to AMR. Fluoroquinolone and cephalosporin exposures were highly predictive of further AMR, yet nitrofurantoin and, to a lesser extent, amoxicillin/clavulanate had fewer associations with AMR induction and resistance to these antimicrobials was less associated with any exposure. This nationwide study of community-related UTIs shows significant AMR rates for commonly used oral antimicrobials even in young fit adults. Nitrofurantoin proved once more to be an adequate empirical choice regardless of previous exposures, having a less detrimental effect on future AMR. Conversely, both resistance to fluoroquinolones following previous exposures and the associated heavy ecological burden should deter their common use as first-line agents for UTIs.

Outpatient Treatment of Uncomplicated Urinary Tract Infections in the Emergency Department.

One of the most commonly treated infections in the emergency department (ED) is an uncomplicated urinary tract infection. Multiple classes of antibiotics are frequently used to treat this condition, but not all have equivalent efficacy, and many may confer risks to not only the patient but society as a whole if used on a large scale. These antibiotic selections should also be guided by local antimicrobial susceptibility patterns, and general multidisciplinary recommendations for therapy should be developed on a local scale to assist prescribing patterns. The proactive development of a routine approach to reviewing and addressing positive cultures following discharge from the ED should also be developed and implemented in order to ensure that optimal patient care is provided. The objective of this review is to assess the available literature to isolate which antibiotics and approaches to care are the most appropriate options for treating uncomplicated outpatient urinary tract infections in the ED.

Antibiotics Dispensed to Privately Insured Pregnant Women with Urinary Tract Infections — United States, 2014

Urinary tract infections (UTIs) occur in about 8% of pregnant women, and untreated UTIs can have serious consequences, including pyelonephritis, preterm labor, low birth weight, and sepsis (1). Pregnant women are typically screened for UTIs during early pregnancy, and those with bacteriuria are treated with antibiotics (1,2). Antibiotic stewardship is critical to improving patient safety and to combating antibiotic resistance. Because of the potential risk for birth defects, including anencephaly, heart defects, and orofacial clefts, associated with use of sulfonamides and nitrofurantoin during pregnancy (3), a 2011 committee opinion from the American College of Obstetricians and Gynecologists (ACOG) recommended that sulfonamides and nitrofurantoin may be prescribed in the first trimester of pregnancy only when other antimicrobial therapies are deemed clinically inappropriate (4). To assess the effects of these recommendations, CDC analyzed the Truven Health MarketScan Commercial Database* to examine antibiotic prescriptions filled by pregnant women with UTIs. Among 482,917 pregnancies in 2014, 7.2% of women had an outpatient UTI diagnosis during the 90 days before the date of last menstrual period (LMP) or during pregnancy. Among pregnant women with UTIs, the most frequently prescribed antibiotics during the first trimester were nitrofurantoin, ciprofloxacin, cephalexin, and trimethoprim-sulfamethoxazole. Given the potential risks associated with use of some of these antibiotics in early pregnancy and the potential for unrecognized pregnancy, women's health care providers should be familiar with the ACOG recommendations and consider the possibility of early pregnancy when treating women of reproductive age.

Fosfomycin efficacy and emergence of resistance among Enterobacteriaceae in an in vitro dynamic bladder infection model.

Urinary tract infections (UTIs) are among the most common bacterial infections and a frequent indication for antibiotic use. Fosfomycin, an important oral antibiotic for outpatient UTIs, remains a viable option for MDR uropathogens. We aimed to perform pharmacodynamic profiling simulating urinary concentrations to assess the adequacy of the current dosing regimen. A dynamic in vitro bladder infection model was developed, replicating urinary fosfomycin concentrations after gastrointestinal absorption, systemic distribution and urinary elimination. Concentrations were measured by LC-MS/MS. Twenty-four Enterobacteriaceae strains (Escherichia coli, Klebsiella pneumoniae and Enterobacter cloacae; MIC range 0.25-64 mg/L) were examined. Pathogen kill and emergence of resistance was assessed over 72 h. Observed in vitro fosfomycin concentrations accurately simulated urinary fosfomycin exposures (Tmax 3.8 ± 0.5 h; Cmax 2630.1 ± 245.7 mg/L; AUC0-24 33 932.5 ± 1964.2 mg·h/L). Fifteen of 24 isolates regrew, with significant rises in fosfomycin MIC (total population MIC50 4 to 64 mg/L, MIC90 64 to > 1024 mg/L, P = 0.0039; resistant subpopulation MIC50 128 to > 1024 mg/L, MIC90 >1024 mg/L, P = 0.0020). E. coli and E. cloacae isolates were killed with pharmacokinetic/pharmacodynamic EI50 of fAUC0-24/MIC = 1922, fCmax/MIC = 149 and fTime>4×MIC = 44 h. In contrast, K. pneumoniae isolates were not reliably killed. Using dynamic in vitro simulations of urinary fosfomycin exposures, E. coli and E. cloacae isolates with MIC >16 mg/L, and all K. pneumoniae isolates, were not reliably killed. Emergence of resistance was significant. This challenges fosfomycin dosing and clinical breakpoints, and questions the utility of fosfomycin against K. pneumoniae. Further work on in vitro dose optimization is required.

Antibiogram, Clinical Practice Guidelines, and Treatment of Urinary Tract Infection

Abstract Antibiotic resistance challenges nurse practitioners' treatment of simple outpatient urinary tract infections in young females who present with genitourinary symptoms. Prescribing antibiotics is complicated by the emergence of resistant gram-negative urinary tract pathogens. An antibiogram aids nurse practitioners in determining prescribing information based on local resistance patterns, and a clinical practice guideline provides evidence-based recommendations for prescribing antibiotics. Prescribing based on resistance patterns improves the chances of the initial antibiotic treatment to cure and mitigates antibiotic resistance.

MP11-14 COST EFFECTIVENESS OF TARGETED ANTIMICROBIAL THERAPY IN TRANSRECTAL ULTRASOUND-GUIDED PROSTATE BIOPSY

You have accessJournal of UrologyInfections/Inflammation/Cystic Disease of the Genitourinary Tract: Prostate & Genitalia II1 Apr 2017MP11-14 COST EFFECTIVENESS OF TARGETED ANTIMICROBIAL THERAPY IN TRANSRECTAL ULTRASOUND-GUIDED PROSTATE BIOPSY Alaya Yassein, Jean-Eric Tarride, and Timothy Davies Alaya YasseinAlaya Yassein More articles by this author , Jean-Eric TarrideJean-Eric Tarride More articles by this author , and Timothy DaviesTimothy Davies More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2017.02.415AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Prophylactic antibiotics are recommended in the American Urological Association (AUA) guidelines to reduce infectious complications following transrectal prostate biopsy (TRPB). Evidence for fluoroquinolone (FQ) prophylaxis is strong but high rates of FQ resistance worldwide have led to increased incidence of post-biopsy infections. Targeted antimicrobial prophylaxis based on rectal swab and culture can decrease rates of post-biopsy infections. To our knowledge, this will be the first study in North America to comprehensively analyze the cost utility of rectal swabs as a tool to reduce infectious complications after prostate biopsy. METHODS A decision analytic model was prepared to compare costs of TRPB infectious complications (no infection, outpatient prostatitis, and inpatient prostatitis) among patients who had standard three-day ciprofloxacin prophylaxis compared to targeted three-day antimicrobials. Rates of infection were based on a recent large meta-analysis and rates of resistance were based on local institutional data. Costs were calculated based on hospital-derived data regarding average cost of inpatient stay, regional costs of common oral and intravenous antibiotics, and lab estimates of labour and material costs for investigations. These were all based on Canadian dollars (CAD). Quality-adjusted life years (QALYs) were calculated based on standard utility values for healthy middle-aged men, outpatient urinary tract infections (UTIs), and inpatient UTIs (as a surrogate for prostatitis). Several presumptions were made to produce a typical index patient of a man fifty to seventy years of age who is otherwise healthy and has no known multi-drug resistant organisms. RESULTS Culture-guided prophylaxis resulted in reduced cost compared to standard prophylaxis ($77 CAD versus $143 CAD) and reduction in quality-adjusted life years (QALYs) by 0.00051. Increasing the cost of performing rectal swabs from $31 CAD to 95CAD causes the two arms to equalize at $141 CAD. Utilizing standard prophylaxis, compared to targeted, would result in an $83 CAD increase in cost to the patient. CONCLUSIONS The use of rectal swabs prior to prostate biopsy for targeted prophylactic antimicrobial therapy is both less costly and confers a greater quality of life compared to standard ciprofloxacin prophylaxis. © 2017FiguresReferencesRelatedDetails Volume 197Issue 4SApril 2017Page: e142 Advertisement Copyright & Permissions© 2017MetricsAuthor Information Alaya Yassein More articles by this author Jean-Eric Tarride More articles by this author Timothy Davies More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Effect of diabetes mellitus on postoperative endoscopic sinus surgery outcomes.

Endoscopic sinus surgery (ESS) has become the treatment of choice for a variety of nasal conditions. The purpose of this study was to analyze the effect of diabetes mellitus (DM) on postoperative outcomes in ESS. Data on endoscopic sinus surgery performed from 2005 to 2013 were collected from the American College of Surgeons National Surgical Quality Improvement (ACS-NSQIP) database. Two groups were created, based on the presence of a DM diagnosis, and were analyzed for preoperative variables, comorbidities, and postoperative complications using SPSS statistical software. There were 644 patients included in the analysis, 85 of whom (13.2%) had a diagnosis of DM. Patients with DM were more likely to have higher rates of preoperative dyspnea and hypertension. After accounting for confounding factors, DM patients undergoing ESS were at higher risk of overall medical complications, pneumonia, unplanned reintubation, ventilator use of >48 hours, and mortality. However, after separating patients into outpatient and inpatient groups, DM was found to be an independent predictor of urinary tract infection in outpatients and of ventilator use >48 hours in inpatients. DM patients undergoing ESS are at increased risk for postoperative medical complications. However, DM does not appear to increase the postoperative surgical complication rate in this population. Furthermore, DM does not appear to have an impact on ESS mortality, readmission, or reoperation rates.

Right Colectomy and Abdominal Perineal Resection for Cancer: Do Urinary Tract Infections Impact Outcomes?

We aim to assess the patient factors and concomitant infectious outcomes associated with urinary tract infection (UTI) occurrence and the impact of UTI on length of stay (LOS), re-admission, and death in a colorectal surgical population. National Surgical Quality Improvement Program User Data for right colectomy and abdominal perineal resection (APR) procedures for cancer between 2006 and 2012 were analyzed. Concomitant infectious complications and timing of UTI diagnosis, inpatient versus outpatient, were considered. We identified 7,615 right colectomies with 107 (1.4%) UTIs and 2,493 APRs with 88 (3.5%) UTIs (p < 0.001). On multivariable analysis and correction for other post-operative complications, UTI remained statistically correlated with prolonged LOS for right colectomy and APR (LOS increases of 59.0% and 37.4%, respectively, p < 0.001) but not death. Patients with a diagnosis of UTI after discharge showed significantly increased re-admission rates compared with UTI diagnosis before discharge (37.7% vs. 9.7%, p < 0.001). After excluding deaths, outpatient UTI occurrences, and correcting for other infectious complications, UTI is associated with increased LOS but is not correlated with re-admission or death. Outpatient occurrence of UTI after hospital discharge is associated with a dramatic re-admission rate of 37.7%.

An Estimate of Inappropriate Antibiotic Prescribing Rates for Outpatient Uncomplicated Urinary Tract Infections.

An Estimate of Inappropriate Antibiotic Prescribing Rates for Outpatient Uncomplicated Urinary Tract Infections.

Urinary Uromodulin and Risk of Urinary Tract Infections: The Cardiovascular Health Study

Laboratory studies suggest that urinary uromodulin, the most common protein in the urine of healthy adults, may protect against urinary tract infection (UTI). Epidemiologic studies evaluating this relationship in humans are lacking. Prospective longitudinal cohort study. 953 participants enrolled in the Cardiovascular Health Study. Uromodulin assayed using enzyme-linked immunosorbent assay in spot urine samples. Composite of outpatient UTI events or UTI-related hospitalizations and each of them individually identified using International Classification of Diseases, Ninth Revision (ICD-9) codes using negative binomial regression with robust standard errors adjusted for age, race, sex, body mass index, diabetes, estimated glomerular filtration rate, and urinary albumin and urinary creatinine excretion. Median uromodulin level was 25.9 (IQR, 17.3-38.9) μg/mL, mean age of participants was 78 years, 61% were women, and 15% were black. There were 331 outpatient UTI events and 87 UTI-related hospitalizations among 186 participants during a median 9.9 years of follow-up. Persons in the highest quartile (>38.93μg/mL) of uromodulin concentration had a significantly lower risk for the composite outcome (incidence rate ratio [IRR], 0.47; 95% CI, 0.29-0.79) compared with those in the lowest quartile (≤17.26μg/mL). This association remained significant for outpatient UTI events (highest vs lowest quartile even after excluding those with prior UTI: IRR, 0.42; 95% CI, 0.23-0.77). The direction of association with UTI hospitalization was similar, but not statistically significant (IRR, 0.78; 95% CI, 0.39-1.58). Use of ICD-9 codes to identify outcomes and lack of generalizability to younger populations. High urinary uromodulin levels are associated with lower risk for UTI in older community-dwelling adults independent of traditional UTI risk factors. This finding supports prior laboratory data indicating a protective role of uromodulin against UTI. Further research is needed to understand if this may lead to new treatments to prevent or treat UTI.

Prevalence and current antibiogram trend of bacterial isolates of urinary tract infections in outpatients at Helping Hands Community Hospital, Kathmandu, Nepal

Prevalence and current antibiogram trend of bacterial isolates of urinary tract infections in outpatients at Helping Hands Community Hospital, Kathmandu, Nepal