Urine Culture Research Articles

Investigation of the Effects of N-acetylcysteine and Selenium on Vesicoureteral Reflux Nephropathy: An Experimental Study

IntroductionThis study aimed to investigate the effects of N-acetylcysteine (NAC) and selenium (Se) on vesicoureteral reflux (VUR) nephropathy. MethodsA total of 44 rabbits in 7 groups, namely group 1 (Control), group 2 (VUR + sterile urine), group 3 (VUR + sterile urine + NAC), group 4 (VUR + sterile urine + Se), group 5 (VUR + infected urine), group 6 (VUR + infected urine + NAC) and group 7 (VUR + infected urine + Se), were used. 99mTc Dimercaptosuccinic acid renal scan (DMSA), cystogram and urine culture were performed both at the beginning and end of the study. Left VUR was created surgically, and E. coli was inoculated in infected urine groups. NAC and Se were administered daily for 21 days. Malondialdehyde (MDA) measurement, inflammatory response scores (IRSs), and cicatrization response scores (CRSs) in renal tissues were evaluated. ResultsVUR did not reduce left renal uptake values in neither group 2 nor group 5. MDA levels of the left kidney were significantly higher in group 5 compared to group 1 (p = 0.001). There was no significant difference in MDA levels between group 5 and group 6, and between group 5 and group 7. Left kidney IRSs were found to be higher in all other groups except group 2 compared to the control group (p < 0.001). Left kidney CRSs were significantly higher in group 5 compared to group 2 (p = 0.026), group 6 (p < 0.001) and group 7 (p = 0.006). ConclusionA decrease in renal functions was not observed in VUR, even if there was infection. When CRSs were evaluated, NAC and Se had protective effects in terms of scar formation in VUR nephropathy. Type of StudyExperimental animal study. Levels of EvidenceN/A.

Comparable Antibacterial Effects of Silver and Iron Oxide Nanoparticles on Urinary Calculi Obtained After Percutaneous Nephrolithotomy

Background: In recent years, science and industry have focused on preparing nanoparticles (NPs). Due to the resistance of bacteria to antibiotics, there is an overwhelming need to find effective antimicrobials with fewer side effects. Objectives: The aim of this study was to synthesize silver and iron oxide NPs and investigate their antimicrobial effects on bacteria isolated from urinary stones. Methods: Cases of urolithiasis from 45 patients with staghorn stones, extracted through percutaneous nephrolithotomy (PCNL), were included in the study. Urinary stone cultures were performed, and the isolation and identification of bacteria were done using standard microbiological techniques. Silver and iron oxide NPs were synthesized, and the minimum bactericidal concentration (MBC) and minimum inhibitory concentration (MIC) were evaluated for the isolates. Results: Seventeen (60.7%) out of 28 positive cultured cases of the isolated bacteria were gram-negative, and 11 (39.3%) were gram-positive. The most abundant isolated bacterium was Escherichia coli, with 13 cases (46.4%). The antibacterial effects of silver and iron oxide NPs revealed that the maximum inhibitory zone for Ag NPs at 1000 ppm was 23 mm, and for Fe3O4 NPs, it was 18.5 mm. The MIC was 180 µg/mL for Ag and 250 µg/mL for Fe3O4. The MBC was 228 µg/mL for Ag and 300 µg/mL for Fe3O4. Conclusions: Nanoparticles exhibited antibacterial effects on the bacteria studied in a concentration-dependent manner. Ag NPs showed a more pronounced bactericidal effect than Fe3O4 NPs. As a result, these two NPs demonstrated effective antibacterial activity against both gram-positive and gram-negative bacteria.

Prognostic factors for the success of BPH/BPO surgery in patients with suprapubic tube

Introduction. In patients with suprapubic tube (SPT) surgical restoration of voiding is not 100% successful. Sometimes urination is inadequate or not recovered at all.Objective. To determine factors influencing the outcomes of benign prostatic hyperplasia / benign prostate obstruction (BPH/BPO) surgery in patients with cystostomy drainage.Materials &amp; methods. The study included 52 men with suprapubic tube initially placed for urinary retention caused by prostate hyperplasia. Afterwards, all patients underwent transurethral resection of the prostate. The age of the patients ranged from 48 to 85 years old. Clinical and urodynamic data of the patients were analysed, restoration of adequate urination after surgery was evaluated as well. We took into account patients age, IPSS scores, bacterial growth in the urine culture test, number of episodes of urinary retention, volume of urinary retention prior to cystostomy, prostate volume, intravesical prostate growth, detrusor overactivity and ability to void in the presence of SPT.Results. We were unable to achieve adequate bladder emptying after transurethral resection of the prostate in 4 (7.6%) patients. These patients required continued bladder drainage after surgery. In 48 (92.4%), adequate urination was restored after surgery and cystostomy drains were removed. Patients with one or more of the following characteristics were more likely to experience a failure of surgical treatment: age over 80, residual urine volume over 1500 mL, and absence of overactive bladder.Conclusion. The study indicates that use of cystometry prior to BPH/BPO surgery is reasonable in such patients. Feasibility of BPH/BPO surgery for this group of patients should be considered individually.

Urine microbiota in non-muscle-invasive bladder cancer and approaches to its detection

Introduction. There is evidence of a connection between infectious and inflammatory lesions of the lower urinary tract and bladder cancer (BCa). However, there is virtually no data on the urine microbiota of middle-aged and elderly men with suspected BCa. This knowledge is extremely important from the point of view of studying the role of the infectious-inflammatory hypothesis in the genesis of BCa.Objective. To conduct a comparative assessment of the microbiota of bladder urine obtained during natural urination and bladder catheterization through standard and extended cultural studies in men with a presumptive diagnosis of non-muscle-invasive bladder cancer (NMIBC).Materials &amp; methods. The prospective comparative study with consecutive patient recruitment included 23 men older than 45 years with suspected NMIBC based on clinical, laboratory and sonographic data, as well as with no history of infectious and inflammatory diseases of the kidneys and urinary tract, including sexually transmitted infections and recurrent infections of other organs and systems. A midstream urine samples and catheter-drained urine immediately before urethrocystoscopy were subjected to bacteriological analysis. Urine culture study was carried out using a standard set of nutrient media under aerobic cultivation conditions and an expanded set of nutrient media under aerobic and anaerobic cultivation conditions.Results. An anaerobic spectrum of microorganisms was predominantly detected in the urine of patients with suspected NMIBC. Moreover, Peptococcus spp. was more often found among anaerobic taxa. (70%), Eubacterium spp., Propionibacterium spp. (45% each, respectively), among representatives of the aerobes — Corynebacterium spp. (60%), S. lentus (up to 45%), S. haemolyticus (35%) and E. faecalis (30%). Data from a comparative analysis of the detection frequencies of microorganisms depending on the method of collecting material and the set of media for cultivation showed that more isolates are isolated in the midstream urine samples than in the study of catheter urine (2.9- and 1.9-fold with the standard and extended sets of media, respectively). In addition, when performing an extended bacteriological study compared to the standard method, the detection of microorganisms is 3.5-fold higher when examining an average portion of urine and 5.1-fold higher when examining catheter urine. The average number of microorganisms per one patient is also higher when using the extended method (midstream portion — 4.7 ± 1.9; catheterised urine — 2.3 ± 1.0) in comparison with the standard one (midstream portion — 1.3 ± 0.9; catheterised urine — 0.3 ± 0.5).Conclusion. Middle-aged and older men with NMIBC are characterized by asymptomatic bacteriuria in the form of a wide range of aerobic and anaerobic microorganisms. The urine pattern obtained with a urethral catheter contains a significantly narrower range of bacteria compared to the sample obtained through natural urination. It is advisable to carry out an extended cultural urine examination to study the characteristics of the microbiota / microbiome of the urine of the bladder immediately before the urethrocystoscopy procedure by collecting urine with a urethral catheter.

Machine learning models to predict systemic inflammatory response syndrome after percutaneous nephrolithotomy

ObjectiveThe objective of this study was to develop and evaluate the performance of machine learning models for predicting the possibility of systemic inflammatory response syndrome (SIRS) following percutaneous nephrolithotomy (PCNL).MethodsWe retrospectively reviewed the clinical data of 337 patients who received PCNL between May 2020 and June 2022. In our study, 80% of the data were used as the training set, and the remaining data were used as the testing set. Separate prediction models based on the six machine learning algorithms were created using the training set. The predictive performance of each machine learning model was determined by the area under the receiver operating characteristic curve (AUC), accuracy, sensitivity and specificity using the testing set. We used coefficients to interpret the contribution of each variable to the predictive performance.ResultsAmong the six machine learning algorithms, the support vector machine (SVM) delivered the best performance with accuracy of 0.868, AUC of 0.942 (95% CI 0.890–0.994) in the testing set. Further analysis using the SVM model showed that prealbumin contributed the most to the prediction of the outcome, followed by preoperative urine culture, systemic immune-inflammation (SII), neutrophil to lymphocyte ratio (NLR), staghorn stones, fibrinogen, operation time, preoperative urine white blood cell (WBC), preoperative urea nitrogen, hydronephrosis, stone burden, sex and preoperative lymphocyte count.ConclusionMachine learning-based prediction models can accurately predict the possibility of SIRS after PCNL in advance by learning patient clinical data, and should be used to guide surgeons in clinical decision-making.

Escherichia col Resistance in Type 2 Diabetes Mellitus with Urinary Tract Infection (UTI)

The Latin and Greek words "diabetes" and "mellitus," respectively, signify sweet and siphon. Diabetes mellitus (DM) is a metabolic disease marked by abnormally elevated blood glucose levels. DM can be divided into two categories: types 1 and 2. T2DM is hypothesized to affect middle-aged and older individuals who have maintained hyperglycemia as a result of bad eating habits and lifestyle choices. 45 urine samples from diabetics with UTIs of different ages were gathered for this study at the National Diabetes Center of Al-Mustansiriyah University in Baghdad Province, Iraq, between October 2023 and February 2024. The samples were handled carefully in the laboratory utilizing the right protocols to avoid any contamination. To categorize bacterial species in the urinary tract, biochemical assays, the standard urine culture (SUC), and other techniques were employed (cultural characteristics, vitek2 system). E. coli made up 67% of the bacteria that were identified from the urine of T2DM patients who had UTIs. In this investigation, E. coli displayed a high percentage of sensitivity to Nitrofurantoin, Erythromycin, Tetracycline, Oxyacillin, Vancomycin, Teicoplanin, and Imipenem (97%) but resistance to Moxifloxacin, Meropenem, Tigecyclin, Ampicillin, Cefazolin, Ceftriaxone, Ertapenem, Cefoxitin, and Nalidixic acid with rate of 100%.

An artificial intelligence-driven support tool for prediction of urine culture test results

Background and aimsWe aimed to develop an easily deployable artificial intelligence (AI)-driven model for rapid prediction of urine culture test results. Material and MethodsWe utilized a training dataset (n = 34,584 urine samples) and two separate, unseen test sets (n = 10,083 and 9,289 samples). Various machine learning models were compared for diagnostic performance. Predictive parameters included urinalysis results (dipstick and flow cytometry), patient demographics (age and gender), and sample collection method. ResultsAlthough more complex models achieved the highest AUCs for predicting positive cultures (highest: multilayer perceptron (MLP) with AUC of 0.884, 95% CI 0.878–0.89), multiple logistic regression (MLR) using only flow cytometry parameters achieved a very good AUC (0.858, 95% CI 0.852–0.865). To aid interpretation, prediction results of the MLP and MLR models were categorized based on likelihood ratio (LR) for positivity: highly unlikely (LR 0.1), unlikely (LR 0.3), grey zone (LR 0.9), likely (LR 5.0), and highly likely (LR 40). This resulted in 17%, 28%, 34%, 9%, and 13% of samples falling into each respective category for the MLR model and 20%, 26%, 31%, 7%, and 16% for the MLP model. ConclusionsIn conclusion, this robust model has the potential to assist clinicians in their decision-making process by providing insights prior to the availability of urine culture results in a significant portion of samples (∼2/3rd).

658 Treatment Outcomes Among Patients with Recurrent Urinary Tract Infections Using a Multidisciplinary Management approach in a Complex UTI Clinic: A 20-Months’ Experience

Abstract Aim Our aim was to assess the treatment outcomes among patients with recurrent UTIs managed in a novel multidisciplinary complex UTI clinic started by Department of Urology at a single tertiary care centre, over a 20-month period. Method In view of persistently increasing burden and prevalence of antibiotic resistance associated with UTIs, a multidisciplinary complex UTI clinic, is started by Urologists supported by specialist nurses and microbiologists was started in April 2021. A prospectively maintained database of 176 patients {(median age 57.4 years (14-89 years) and (Male:Female ratio of 1:10)} who were referred to our clinic, within a 20-month period was reviewed. Patient demographics, urine culture results (causative bacterial organism and antibiotic sensitivities), investigations performed, and treatment outcomes were recorded. Pre-treatment QoL (Quality of Life) and post-treatment PGI-I (Patient global impression of improvement Scale) Score were measured. Results Escherichia Coli (69%) was identified as the most common causative organism. 30% patients had multi-resistant bacterial organism on urine culture. Abnormal Flexible cystoscopy, Renal Tract USS, CT Urogram was reported in 14%, 13% and 11% respectively. All patients received information on general cystitis prevention measures. 46 (26%) required intra-vesical treatment (Gentamicin 12%, Amikacin 1% and Glycosaminoglycans 13%). 71% patients remained infection free on follow up. Pre-treatment 64% patients reported significant impact on their QoL. 88.6% (94) of the 106 patients, followed up after the completion of treatment had good improvement on PGI-I scale (Table 1). Conclusions A dedicated complex UTI clinic service with multidisciplinary treatment approach can be efficient in managing recurrent UTIs.

The Effect of Enhanced Recovery After Surgery Protocol on Surgical Site Infections in Liver Transplantation.

Background: Liver surgeries are treatment modalities that require careful pre- and postoperative follow-up for both the surgeon and the patient. Infections are the leading causes of morbidity and mortality after liver transplantation. Infections are the most frequent cause of death between 30 and 180 days after liver transplantation. We aimed to investigate the effect of the Enhanced Recovery After Surgery (ERAS) protocol on the prevention of infections in liver transplant patients. Patients and Methods: The study included patients who underwent liver transplantation in Ataturk University Organ Transplantation Center between 2017 and 2022. Two patient groups with and without ERAS were formed. Blood and urine cultures were collected retrospectively, and those with positive blood cultures for bacteremia were recorded as infection development. The development of infection between the two groups was statistically compared. Also, all patients' length of intensive care stay, length of hospital stay, and duration of antibiotic use were recorded. These parameters were compared between both groups. Results: There was a statistically significant difference between the two groups in terms of infection development (p: 0.01). There was a statistically significant difference between the two groups in terms of duration of antibiotic use and length of hospital stay (Mann-Whitney U test; p: 0.00, p: 0.04, respectively). There was no statistically significant difference between the two groups in terms of length of intensive care stay. Conclusion: We concluded that the introduction of an ERAS protocol was associated with fewer infections, thus shortening the duration of antibiotic therapy and length of hospital stay, although the standardization of the protocols is difficult, especially in liver transplants.

Ancillary Benefit of Microbiology Culture Diagnostic Stewardship: Decreasing Healthcare’s Climate Impact

Abstract We calculated weights of blood, urine, and endotracheal tube culture supplies and quantified greenhouse gas emissions emitted for disposal of these supplies. Of note, disposal related emissions for a positive blood and endotracheal tube culture are each equivalent to driving 0.6 and 0.4 miles, respectively, in a gasoline-powered vehicle.

Supplementation with Highly Standardized Cranberry Extract Phytosome Achieved the Modulation of Urinary Tract Infection Episodes in Diabetic Postmenopausal Women Taking SGLT-2 Inhibitors: A RCT Study.

Urinary tract infections (UTIs) are the most common bacterial infections in postmenopausal women, and women with diabetes are possibly at a higher risk. The aim of this study is to evaluate the potential benefit on the prevention of UTI episodes, assessed by urinalysis and urine culture (primary outcome) after two, four and six months, of daily oral dietary supplement (120 mg highly standardized cranberry extract phytosome), compared to placebo, in diabetic postmenopausal women taking SGLT-2 inhibitors. Forty-six subjects (mean age 72.45 ± 1.76) completed the study (23 placebo/23 supplement). Considering UTI episodes, during the six-month supplementation period, an increase of 1.321 (95% CI: -0.322; 2.9650) was observed in the placebo group, while it remained at a steady value of 0.393 (95% CI: -4.230; 5.016) in the supplemented group. Regarding UTI episodes, in both groups, interaction between times for supplementation was statistically significant (p = 0.001). In particular, at follow-up 4, 9% of the placebo group showed infection versus only 3% with cranberry supplementation. Glycaemia and glycated hemoglobin values (secondary outcomes) were not modified at the end of six months with respect to the basal values in both groups, as expected. While in terms of quality of life per the SF-12 health questionnaire, there were no differences between the two groups, an improvement in SF-12 quality of life was observed in both groups (six months vs. basal). In conclusion, highly standardized cranberry extract phytosome supplementation reduced UTI recurrence.

Investigating Urinary Pathogens and Their Antibiotic Resistance: A Cross-Sectional Urine Culture Study.

Urinary tract infections (UTIs) are among the most prevalent infectious diseases. Females are more affected than males. The primary culprit is Escherichia coli. Multiple research investigations have documented widespread antimicrobial resistance in uropathogens, sparking global concerns, especially regarding the rise of multidrug resistance (MDR). This cross-sectional study was conducted from December 2023 to March 2024. A non-probability purposive sampling technique was employed to select participants, and informed consent was obtained from them. Data were extracted from the culture and sensitivity reports of these patients. The collected data were meticulously entered into IBM SPSS Statistics for Windows, Version 21 (IBM Corp.,Armonk, NY). The findings were then presented using a blend of percentages and numerical figures, offering a clear and concise representation of the data. Our study of 313 participants showed a higher prevalence of UTIs in females (219, 70%) compared to males (94, 30%). E. coli and Citrobacter were the predominant pathogens, with E. coli and Citrobacter more common in females, while Enterobacter and Staphylococcus were more prevalent in males. Antibiogram analysis revealed sensitivities to specific drugs like nitrofurantoin and meropenem, while resistance was observed against others, including polymyxin B and ampicillin. These findings stress the need for tailored UTI treatment approaches. In conclusion, our research highlights a concerning trend of escalating antibiotic resistance among Pakistani patients with UTIs. Tobramycin B, ticarcillin-clavulanic acid, ampicillin, and clotrimazole exhibited the highest resistance rates, while imipenem, meropenem, nitrofurantoin, sulfonamides, and tigecycline demonstrated notable sensitivity. These findings emphasize the urgent need for the exploration of alternative treatment options to combat rising resistance levels effectively.

Increased prevalence of non-E. coli bacteria-caused urinary infection in neonates delivered by cesarian section

to assess the association between delivery mode and causative pathogens of infants with urinary tract infections. We conducted a retrospective analysis of the medical records of neonates delivered in a tertiary academic pediatric hospital and diagnosed with urinary tract infections between January 1,2013 and December 31,2017. Excluded were newborns with urinary tract infections post-urological procedures or neurogenic bladders. The retrieved data included demographic characteristics, clinical presentations, laboratory findings, urine cultures, and renal imaging results. Multivariable logistic regressions were employed to identify associations. 95 of the 131 neonates' (72.5%) cultures were positive for Escherichia coli. Neonates born via cesarean section (C/S) had a significantly higher prevalence (12/25, 48%) of non-Escherichia coli infections (p=0.01). The mode of delivery was the only variable associated with non-Escherichia coli infections (odds ratio=3.1, p=0.014). Two of the 12 neonates (17%) with non-Escherichia coli cultures in the C/S group were diagnosed as having dilating vesicoureteral reflux. While the impact of mode of delivery on microbiome composition and UTI risk in the pediatric population is well documented, to the best of our knowledge, our study is the first to evaluate and report on the clinical connection between mode of delivery and neonatal UTIs. Most noteworthy was our finding of an elevated prevalence of non-E. coli cultures in the C/S group (p=0.014, OR 3.1). This bears important clinical implications, particularly in the setting of congenital anomaly of kidney and urinary tract (CAKUT) screening. Our analyses in this study reveal a significant link between delivery by cesarean section and neonatal urinary tract infections with non- Escherichia coli urine cultures. These findings carry implications for vesicoureteral reflux screening in neonates by raising the level of awareness of the association between the 2 factors. Additional prospective studies on larger cohorts are warranted to further elucidate this relationship and refine clinical decision-making in neonatal care.

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.

Moving Beyond the Reflex: Effect of a Clinical Decision Support Tool on Urine Culture Ordering Practices

Background: Interventions targeting urine culture stewardship can improve diagnostic accuracy for urinary tract infections (UTI) and decrease inappropriate antibiotic treatment of asymptomatic bacteriuria. We aimed to determine if a clinical decision support (CDS) tool which provided guidance on and required documentation of the indications would decrease inappropriately ordered urine cultures in an academic healthcare network that already uses conditional (e.g. reflex) urine testing. Methods: In October 2022, four hospitals within one academic healthcare network transitioned to a new electronic health record (EHR). We developed an embedded CDS tool that provided guidance on ordering either a urinalysis (UA) with reflex to urine culture or a non-reflex urine culture (e.g. for pregnant patients) based on the indication for testing (Figure 1). We compared median monthly UA with reflex culture and non-reflex urine culture order rates pre- (8/2017–9/2022) and post- (10/2022–9/2023) intervention using the Wilcoxon rank-sum test. We used interrupted time-series analyses allowing a one-month time window for the intervention effect to assess changes in monthly UA with reflex culture, non-reflex urine culture, and total urine culture order rates associated with the intervention. Using SAS 9.4, we generated Durbin-Watson statistics to assess for autocorrelation and adjusted for this using a stepwise autoregressive model. Result: The median monthly UA with reflex culture order rates per 1000 patient-days were similar pre- and post- intervention at 36.7 (interquartile range [IQR]: 31.0–39.7) and 35.4 (IQR: 32.8–37.0), respectively (Figure 2). Non-reflex and total urine culture rates per 1000 patient-days decreased from 8.5 (IQR: 8.1–9.1) to 4.9 (IQR: 4.7–5.1) and from 20.0 (IQR: 18.9–20.7) to 14.4 (IQR: 14.0–14.6) post-intervention, respectively. Interrupted time-series analyses revealed that the intervention was associated with a decrease in the monthly non-reflex urine culture by 4.8 cultures/1000 patient-days (p&lt; 0.001) and in the total urine culture monthly order rates by 5.0 cultures/ 1000 patient-days (p &lt; 0 .001) [Figures 3a and b]. The UA with reflex order rate did not significantly change with the intervention (not pictured). Conclusion: In an academic healthcare network that already employed conditional urine testing, the implementation of an EHR-based diagnostic stewardship tool led to additional decreases in both non-reflex and total urine cultures ordered.

Impact and Safety of Diagnostic Stewardship to Improve Urine Culture Testing Among Patients with Indwelling Urinary Catheters

Background: Indiscriminate urine culturing of patients with indwelling urinary catheters may lead to overdiagnosis of urinary tract infections, resulting in unnecessary antibiotic treatment and inaccurate reporting of catheter-associated urinary tract infections (CAUTIs) as a hospital quality metric. We evaluated the impact of a computerized diagnostic stewardship intervention to improve urine culture testing among patients with indwelling urinary catheters. Methods: We performed a single-center retrospective observational study at Rush University Medical Center from April 2018 – July 2023. In February 2021, we implemented a computerized clinical decision support tool to promote adherence to our internal urine culture guidelines for patients with indwelling urinary catheters. Providers were required to select one guideline criteria: 1) neutropenia, 2) kidney transplant, 3) recent urologic procedure, 4) urinary tract obstruction; or if none of the criteria were met, then an infectious diseases consultation was required for approval. We compared facility-wide CAUTI rate per 10,000 catheter days and standardized infection ratio (SIR) during baseline and intervention periods using ecologic models, controlling for time and for monthly Covid-19 hospitalizations. In the intervention period, we evaluated how providers responded to the intervention. Potential harm was defined as collection of a urine culture within 7 days of the intervention that resulted in a change in clinical management. Results: In unadjusted models, CAUTI rate decreased from 12.5 to 7.6 per 10,000 catheter days (p=0.04) and SIR decreased from 0.77 to 0.49 (p=0.09) during baseline vs intervention periods. In adjusted models, the CAUTI rate decreased from 6.9 to 5.5 per 10,000 catheter days (p=0.60) (Figure 1) and SIR decreased from 0.41 to 0.35 (p=0.65) during baseline vs intervention periods. Urine catheter standard utilization ratio (SUR) did not change (p=0.36). There were 598 patient encounters with ≥1 intervention. Selecting the first intervention for each encounter, 284 (47.5%) urine cultures met our guidelines for testing and 314 (52.5%) were averted (Figure 2). Of these, only 3 ( &lt; 1 %) had a urine culture collected in the subsequent 7 days that resulted in change in clinical management. Conclusion: We observed a trend of decreased CAUTIs over time, but effect of our diagnostic stewardship intervention was difficult to assess due to healthcare disruption caused by Covid-19. Adverse outcomes were rare among patients who had a urine culture averted. A computerized clinical decision support tool may be safe and effective as part of a multimodal program to reduce unnecessary urine cultures in patients with indwelling urinary catheters.

Diagnostic Stewardship Opportunities for Emergency Department Evaluation of Children with Suspected Urinary Tract Infection

Background: Among children who start antibiotics for suspected urinary tract infection (UTI) in emergency departments (EDs), 40-60% have negative urine cultures or other results inconsistent with UTI. Practices contributing to excess antibiotic exposure are not well understood. The goal of this study was to understand diagnostic and post-encounter follow-up processes in children who received antibiotics, in order to define targets for intervention. Methods: We identified encounters by children evaluated in two pediatric EDs, over 2 months in the first ED and 9 months in the second ED, to balance different visit volumes. Children 2 months-17 years old were included if they had a urinalysis (UA) and/or urine culture performed, were assigned a primary or secondary diagnosis code for UTI, and initiated antibiotics. Patients were excluded if they received antibiotics prior to the encounter, had prior urologic surgery or device placement, or were immunocompromised or pregnant. Data abstracted by chart review included demographics, documented symptoms, test results, and documented urine culture review and management. Possible UTI symptoms per pediatric criteria included fever, dysuria, urinary frequency, urgency, or hesitancy, suprapubic, abdominal or flank pain, foul smelling urine, or new urinary incontinence. In both EDs, nurses review urine cultures and document changes to treatment plans. Final urine culture results were considered inconsistent with UTI if there was 1) no growth or 2) only mixed growth reported with quantity &lt; 1 00,000 colony forming units/ml. Results: Of 150 eligible children, 146 (97%) had at least one UTI symptom and 146 (97%) had abnormal UA Results: Urine cultures were not performed in 27 (18%) children. Of 123 encounters with urine cultures performed, 71 (58%) had results inconsistent with UTI. Though 67/71 cultures were marked as reviewed, 43/67 (64%) of the patients who could have stopped antibiotics per guideline recommendations did not have documented plans to stop. In those who had documented plans to stop antibiotics, nurses reached 20/23 (87%) caregivers by phone to communicate these recommendations. Conclusion: Many children suspected to have UTI at the time of ED evaluation do not meet criteria for UTI. We found that the most frequent departures from evidence-based practice recommendations were 1) not sending urine cultures, and 2) not stopping antibiotics when culture results did not support the suspected UTI diagnosis. Further investigation should explore barriers and facilitators to these evidence-based practices to develop population- and context-specific diagnostic stewardship strategies.

Utilization of multiplex molecular panels for urinary tract infections, Medicare claims, 2016 – 2022

Background: Multiplex molecular tests for infectious diseases can provide highly sensitive results rapidly; however, these tests may more readily detect asymptomatic colonization. There are reports of non-FDA approved laboratory-developed multiplex tests for the diagnosis of urinary tract infections (UTI). Differentiating UTI from asymptomatic bacteriuria is challenging, especially in older adults. The increased sensitivity of multiplex tests may exacerbate this challenge. We sought to describe the use of multiplex testing for UTIs in Medicare claims. Methods: Multiplex testing was identified using carrier claims submitted by non-institutional providers using the Chronic Conditions Warehouse for 2016 – 2022. Because there are no CPT-4 codes specifying UTI multiplex testing, we included claims as described in Figure 1 and categorized claims based on the primary ICD-10-CM diagnosis. The payment amounts for line items related to testing for infectious agents were summed. Laboratories were counted using CLIA numbers listed on corresponding claims. Beneficiaries residing in a nursing home at the time of their claim were identified using stay information derived from the Minimum Dataset 3.0. For comparison, similar characteristics among carrier claims with a CPT-4 code indicating urine culture were also described. Results: Claims for unspecified multiplex molecular tests overall have increased, driven by increases in claims with a primary UTI diagnosis (from 8,521 in 2016 to 386,943 in 2022), while urine cultures have not (Figure 1). In 2022, 65% of all unspecified multiplex tests were linked to a diagnosis of UTI; UTI multiplex claims were associated with 647 laboratories. For UTI claims, the median cost per claim for line items related to multiplex testing was $589 compared to $13 for urine culture-related line items. Overall, 8% of UTI multiplex claims were for beneficiaries residing in a nursing home. Conclusions: Claims for non-FDA approved unspecified multiplex tests associated with a primary diagnosis of UTI have increased &gt;45-times between 2016-2021 and have &gt;45-times higher median costs than urine cultures. The use of this testing in the Medicare population, including nursing home residents, is of potential concern given that inappropriate treatment of asymptomatic bacteriuria has been described to be common in older adults. Research is needed to outline use cases where UTI multiplex testing may be beneficial. Appropriate use of diagnostic testing is important to minimize diagnostic errors and avoid unnecessary antibiotic use.

Characteristics of Bacteria in Urine and Stones from Patients Treated with Percutaneous Nephrolithotomy and Association with Postoperative Infection.

The purpose of this study was to identify bacterial differences between urine cultures (UC) and stone cultures (SC) in patients with complex kidney stones and to determine any correlation with post-percutaneous nephrolithotomy Systemic Inflammatory Response Syndrome (SIRS). Perioperative data of 1055 patients with complex kidney stones treated with first-stage Percutaneous Nephrolithotomy (PCNL) from September 2016 until September 2021 were included. Preoperative mid-stream urine samples and surgically obtained stone material were subjected to bacterial culture and antibiotic sensitivity tests. Preoperatively, antibiotic usage was determined by the UC or local bacterial resistance patterns. After PCNL treatment, antibiotic selection was guided by stone bacterial culture result and clinical symptoms. The effect of different preoperative antibiotic regimens based on urine cultures and postoperative antibiotic treatment based on stone cultures were assessed. Positive stone cultures (SC+) were significantly more common than positive urine cultures (UC+) (31.9% vs 20.9%, p < 0.05). Escherichia coli (E. coli) was the most common uropathogen in both urine (54.3%) and stones (43.9%). The difference was statistically significant (p < 0.05). Moreover, UC+SC-, UC-SC+, UC+SC+, and preoperative serum creatinine were independent risk factors of postoperative SIRS. The incidence of SIRS in the UC+SC+ patients with different bacteria in stones and urine (51.6%) was higher than that in other culture groups. The antibiotic resistance of E. coli inside the stone was increased when prolonged preoperative antibiotics were administered to UC+ patients. The bacterial spectrum and positive outcome of culture in urine and stones were significantly different. The incidence of postoperative SIRS was highest in patients with UC+SC+ but with different bacteria strains. Prolonged pre-surgical antibiotic treatment apparently induced higher drug resistance for bacteria inside the stone.

Does Urinary Catheter Replacement Prior To Obtaining Urine for Culture Make a Difference?

Background: Indwelling urinary catheters (UCs) generate biofilm that grows over time, raising concern that after several days any culture from a UC may generate a false positive result. Whether and when to replace a UC prior to culture is controversial, with prior studies recommending anywhere from 3 to 14 days as appropriate, but with no conclusive data. We evaluated urine culture results across a large healthcare system where, beginning in 2019, some facilities adopted the practice of changing UC before collection if indwelling for 3 days or more. Method: Analysis was from nursing electronic health record documentation of UC changes and urine cultures collected on patients with indwelling UC in 2022. UC changes were defined as a stop followed by a start within 12 hours. Patient exclusion criteria included a UC other than “temporary/indwelling” and surgical procedure during the admission. Statistics applied Pearson’s Chi-squared test with Yates continuity correction using R Core Team (2023) R: A Language and Environment for Statistical Computing. Result: Total UC episodes meeting criteria was 88,347 across 152 acute care hospitals. Episodes in days was 0-3 for 65%, 4-9 for 29% and &gt;9 for 6%. Most urine cultures were taken at 3 days (p UC Changed? Culture Negative Culture Positive No 4916 (98.8%) 61 (1.2%) Yes 588 (98.7%) 8 (1.3%) Cultures were positive at the same rate whether a UC change occurred or not at &gt;3 days (p=0.96). No difference was found in NHSN reported CAUTI prevalence among the UC change vs. no change in the &gt;3 day groups. Conclusion: Urine culture results do not appear to be impacted by UC change as early as 3 days. UC change without benefit may generate unnecessary costs and complications.