Asymptomatic Bacteriuria.

Asymptomatic bacteriuria, defined as the presence of bacteria in the urine in the absence of urinary symptoms, is a common clinical finding that often warrants a decision about whether to initiate antimicrobial therapy. There are few indications to treat asymptomatic bacteriuria, and inappropriate treatment contributes to the development of antimicrobial resistance. In 2019, the Infectious Diseases Society of America revised its 2005 guidelines on asymptomatic bacteriuria, incorporating new evidence. The updated guidelines recommend screening and appropriate treatment for asymptomatic bacteriuria in pregnant women and in individuals undergoing endourological procedures associated with mucosal trauma. The guidelines recommend against screening and treatment in infants and children; healthy adults, including nonpregnant pre- and postmenopausal women; and patients with diabetes mellitus, long-term indwelling catheters, or spinal cord injuries. The guidelines also recommend against screening and treatment in patients undergoing nonurological surgery, patients who have had a kidney transplant more than one month prior, recipients of other solid organ transplants, or those with impaired voiding following spinal cord injury. Although delirium in older adults can be caused by a urinary tract infection, the guidelines recommend that patients with delirium and no urinary or systemic symptoms be assessed for other causes of delirium, rather than initiating treatment for asymptomatic bacteriuria, because treatment has not been shown to have any beneficial effect on clinical outcomes.

Clinical Practice Guideline for the Management of Asymptomatic Bacteriuria: 2019 Update by the Infectious Diseases Society of America.

Asymptomatic bacteriuria (ASB) is a common finding in many populations, including healthy women and persons with underlying urologic abnormalities. The 2005 guideline from the Infectious Diseases Society of America recommended that ASB should be screened for and treated only in pregnant women or in an individual prior to undergoing invasive urologic procedures. Treatment was not recommended for healthy women; older women or men; or persons with diabetes, indwelling catheters, or spinal cord injury. The guideline did not address children and some adult populations, including patients with neutropenia, solid organ transplants, and nonurologic surgery. In the years since the publication of the guideline, further information relevant to ASB has become available. In addition, antimicrobial treatment of ASB has been recognized as an important contributor to inappropriate antimicrobial use, which promotes emergence of antimicrobial resistance. The current guideline updates the recommendations of the 2005 guideline, includes new recommendations for populations not previously addressed, and, where relevant, addresses the interpretation of nonlocalizing clinical symptoms in populations with a high prevalence of ASB.

Clinical Practice Guideline for the Management of Asymptomatic Bacteriuria: 2019 Update by the Infectious Diseases Society of America.

Asymptomatic bacteriuria (ASB) is a common finding in many populations, including healthy women and persons with underlying urologic abnormalities. The 2005 guideline from the Infectious Diseases Society of America recommended that ASB should be screened for and treated only in pregnant women or in an individual prior to undergoing invasive urologic procedures. Treatment was not recommended for healthy women; older women or men; or persons with diabetes, indwelling catheters, or spinal cord injury. The guideline did not address children and some adult populations, including patients with neutropenia, solid organ transplants, and nonurologic surgery. In the years since the publication of the guideline, further information relevant to ASB has become available. In addition, antimicrobial treatment of ASB has been recognized as an important contributor to inappropriate antimicrobial use, which promotes emergence of antimicrobial resistance. The current guideline updates the recommendations of the 2005 guideline, includes new recommendations for populations not previously addressed, and, where relevant, addresses the interpretation of nonlocalizing clinical symptoms in populations with a high prevalence of ASB.

Infection prevention issues in long-term care.

PURPOSE OF REVIEW: Infections and antimicrobial use are common in residents of long-term care facilities. This review discusses recent articles that address infection prevention and control and antimicrobial stewardship in these facilities. RECENT FINDINGS: National surveys confirm the continuing high prevalence of infections in residents of long-term care facilities, with the greatest risk for patients with the highest acuity and greatest functional disability. Long-term acute care facilities are a unique environment where residents are characterized by high levels of indwelling device use and antimicrobial-resistant organisms. The major determinant of antimicrobial resistance in long-term care facilities is antimicrobial use. The Centers for Disease Control (CDC) has proposed revised evidence-based definitions for surveillance of infections on the basis of the original McGeer criteria. Consensus national performance standards for infection prevention and antimicrobial stewardship programs in long-term care facilities have been developed in a European initiative. Evidence to support the efficacy of infection control programs is limited. Antimicrobial stewardship programs may, however, be effective in reducing inappropriate antimicrobial use. SUMMARY: The extent to which endemic infections or antimicrobial resistance in long-term care facilities can be prevented remains unclear. Efforts to limit infections in these facilities should focus on outbreak prevention and standard procedures for environmental cleaning, food preparation, and hand hygiene, together with optimal resident medical care. Antimicrobial stewardship programs should be implemented.

Asymptomatic bacteriuria.

PURPOSE OF REVIEW: Asymptomatic bacteriuria is a common finding. Inappropriate antimicrobial treatment of asymptomatic bacteriuria has been identified as a major issue for antimicrobial stewardship programs. This review summarizes and evaluates recent studies which extend our knowledge of the occurrence, management, and outcomes of bacteriuria. RECENT FINDINGS: The reported prevalence of bacteriuria is higher in some developing countries than generally reported for developed countries, but reasons for this remain unclear. Clinical studies of young women, renal transplant patients, and patients undergoing minor nontraumatic urologic procedures confirm that treatment of asymptomatic bacteriuria for these populations is not beneficial, and may be harmful. There is also no benefit for treatment of asymptomatic bacteriuria prior to orthopedic surgery to decrease postoperative surgical site infection. Studies continue to report substantial inappropriate antimicrobial use for treatment of asymptomatic bacteriuria. SUMMARY: Recent publications confirm that asymptomatic bacteriuria is benign in most patients. Management strategies for pregnant women with recurrent bacteriuria require further clarification. There is a continuing problem with inappropriate treatment of asymptomatic bacteriuria, and sustainable strategies to optimize antimicrobial use for this problem are needed.

Reducing Treatment of Asymptomatic Bacteriuria: What Works?

Asymptomatic bacteriuria is common, but usually benign. Inappropriate antimicrobial treatment of asymptomatic bacteriuria contributes to negative antimicrobial outcomes. Optimizing antimicrobial use for bacteriuria is a component of antimicrobial stewardship programs and includes key practices of dissemination and implementation of guidelines, laboratory practices which support stewardship, and programs to monitor and implement optimal antimicrobial treatment for urinary infection. These activities vary in their effectiveness, costs, and complexity to institute. Stewardship strategies targeting unique populations with a high prevalence of bacteriuria and for whom symptom assessment is not straightforward need to be further developed and evaluated to support optimal stewardship.

Urinary tract infection in patients with diabetes mellitus.

Urinary tract infection occurs with increased frequency and severity in patients with diabetes mellitus. General host factors enhancing risk for urinary tract infection in diabetics include age, metabolic control, and long term complications, primarily diabetic nephropathy and cystopathy. Alterations in the innate immune system have been described and may also contribute. Treatment of asymptomatic bacteriuria in diabetic patients is not indicated. Early diagnosis and prompt intervention is recommended to limit morbidity of symptomatic infection. Clinical studies comparing management of urinary tract infection in persons with diabetes compared to those without as well as diabetic patients with good or poor glucose control will be necessary to improve care of urinary infection in persons with diabetes mellitus.

International clinical practice guidelines for the treatment of acute uncomplicated cystitis and pyelonephritis in women: A 2010 update by the Infectious Diseases Society of America and the European Society for Microbiology and Infectious Diseases.

A Panel of International Experts was convened by the Infectious Diseases Society of America (IDSA) in collaboration with the European Society for Microbiology and Infectious Diseases (ESCMID) to update the 1999 Uncomplicated Urinary Tract Infection Guidelines by the IDSA. Co-sponsoring organizations include the American Congress of Obstetricians and Gynecologists, American Urological Association, Association of Medical Microbiology and Infectious Diseases-Canada, and the Society for Academic Emergency Medicine. The focus of this work is treatment of women with acute uncomplicated cystitis and pyelonephritis, diagnoses limited in these guidelines to premenopausal, non-pregnant women with no known urological abnormalities or co-morbidities. The issues of in vitro resistance prevalence and the ecological adverse effects of antimicrobial therapy (collateral damage) were considered as important factors in making optimal treatment choices and thus are reflected in the rankings of recommendations.

Update in adult urinary tract infection.

Urinary tract infection remains a common problem for many populations. Recent studies have expanded our understanding of the host innate immune response and its role in the familial association observed for recurrent uncomplicated urinary tract infection in healthy women. Therapeutic management for uncomplicated infection has been compromised by increasing antimicrobial resistance, particularly global dissemination of the CTXM-15 extended spectrum ß-lactamase (ESBL) producing Escherichia coli ST-131 strain. Prevention strategies exploring non-antimicrobial approaches continue to show limited promise, and approaches to limit empiric antimicrobials are now being explored. For complicated urinary tract infection, increasing antimicrobial resistance limits therapeutic options for many patients. In addition to ESBL producing E. coli, NDM-1 E. coli and Klebsiella pneumoniae and other resistant Gram negatives, such as Acinetobacter species, are being isolated more frequently. There has been renewed interest in catheter-acquired urinary tract infection, the most common health-care associated infection, with several recent evidence-based guidelines for infection prevention available. However, technologic progress in development of adherence-resistant catheter materials remains disappointing.

Diagnosis, prevention, and treatment of catheter-associated urinary tract infection in adults: 2009 International Clinical Practice Guidelines from the Infectious Diseases Society of America.

Guidelines for the diagnosis, prevention, and management of persons with catheter-associated urinary tract infection (CA-UTI), both symptomatic and asymptomatic, were prepared by an Expert Panel of the Infectious Diseases Society of America. The evidence-based guidelines encompass diagnostic criteria, strategies to reduce the risk of CA-UTIs, strategies that have not been found to reduce the incidence of urinary infections, and management strategies for patients with catheter-associated asymptomatic bacteriuria or symptomatic urinary tract infection. These guidelines are intended for use by physicians in all medical specialties who perform direct patient care, with an emphasis on the care of patients in hospitals and long-term care facilities.

Developing key performance indicators for prescription medication systems.

OBJECTIVE: To develop key performance indicators that evaluate the effectiveness of a prescription medication system. METHODS: A modified RAND/UCLA appropriateness method was used to develop key performance indicators (KPIs) for a prescription medication system. A broad list of potential KPIs was compiled. A multidisciplinary group composed of 21 experts rated the potential KPIs. A face-to-face meeting was held following the first rating exercise to discuss each potential KPI individually. The expert panel undertook a final rating of KPIs. The final set of KPIs were those indicators where at least 80 percent of experts rated the indicator highly i.e. rating of ≥ 7 on a scale from 1 to 9. RESULTS: 292 KPIs were identified from the published literature. After removing duplicates and combining similar indicators 71 KPIs were included. The final ranking resulted in six indicators being ranked 7 or higher by 80% of the respondents and an additional seven indicators being ranked 7 or higher by ≥70 but ≤80% of respondents. The six selected indicators include four specific disease areas, measure structural and process aspects of health service delivery, and assessed three of the domains of healthcare quality: efficiency, effectiveness, and safety. CONCLUSIONS: These indicators are recommended as a starting point to assess the current performance of prescription medication systems. Consideration should be given to developing indicators in additional disease areas as well as indicators that measure the domains of timeliness and patient-centeredness. Future work should focus on the feasibility of measuring these indicators.

Short-term therapy for urinary tract infection: success and failure.

The pharmacokinetic characteristics of some antimicrobials lead to very high urinary concentrations. This, together with the superficial nature of bladder infection and effective voiding, supports the use of short-course antimicrobial therapy for treatment of acute uncomplicated cystitis. Even a single dose is effective for >90% of episodes for some antimicrobials. Short-course therapy for 3 days is, however, the current accepted standard of therapy for acute uncomplicated urinary tract infection (UTI). Complicated UTI is a more diverse clinical entity. For individuals with some underlying abnormalities, including incomplete drainage of urine or renal failure, short-course therapy is never appropriate. However, some individuals with complicated UTI have adequate urinary emptying, infection limited to the bladder and normal renal function. For these persons, the same principles that promote effective short-course therapy for treatment of acute uncomplicated UTI should also apply. However, clinical studies reported to date do not support the use of short-course therapy for treatment of complicated cystitis. Further studies enrolling well-characterised patient populations with consistent clinical presentations are required to define the role, if any, of short-course therapy in complicated UTI.