Nitrofurantoin: what is the evidence for current UK guidance?

Three days of nitrofurantoin at 100 mg twice daily is recommended as first-line treatment for uncomplicated urinary tract infection (UTI) in evidence-based guidelines across the UK. A review of international guidelines shows that the evidence base has been interpreted in very different ways. UK guidelines are unusual in promoting short (3 day) courses, and we find little direct evidence to support this. Although 'short' courses of antibiotics for other agents may provide optimum balance between providing effective treatment whilst reducing selective pressure driving resistance amongst colonizing microbial flora, it remains unclear that course lengths can be extrapolated to nitrofurantoin. Three days of nitrofurantoin may indeed be a useful intervention in a large group of patients. However, without supporting evidence and because clinical response should be expected to vary widely, it is unclear that establishing and promoting an antibiotic duration for UTI is the best approach to optimizing prescribing in this important area.

Retrospective screening of routine respiratory samples revealed undetected community transmission and missed intervention opportunities for SARS-CoV-2 in the United Kingdom.

In the early phases of the SARS coronavirus type 2 (SARS-CoV-2) pandemic, testing focused on individuals fitting a strict case definition involving a limited set of symptoms together with an identified epidemiological risk, such as contact with an infected individual or travel to a high-risk area. To assess whether this impaired our ability to detect and control early introductions of the virus into the UK, we PCR-tested archival specimens collected on admission to a large UK teaching hospital who retrospectively were identified as having a clinical presentation compatible with COVID-19. In addition, we screened available archival specimens submitted for respiratory virus diagnosis, and dating back to early January 2020, for the presence of SARS-CoV-2 RNA. Our data provides evidence for widespread community circulation of SARS-CoV-2 in early February 2020 and into March that was undetected at the time due to restrictive case definitions informing testing policy. Genome sequence data showed that many of these early cases were infected with a distinct lineage of the virus. Sequences obtained from the first officially recorded case in Nottinghamshire - a traveller returning from Daegu, South Korea - also clustered with these early UK sequences suggesting acquisition of the virus occurred in the UK and not Daegu. Analysis of a larger sample of sequences obtained in the Nottinghamshire area revealed multiple viral introductions, mainly in late February and through March. These data highlight the importance of timely and extensive community testing to prevent future widespread transmission of the virus.

Molecular exploration for Mycoplasma amphoriforme, Mycoplasma fermentans and Ureaplasma spp. in patient samples previously investigated for Mycoplasma pneumoniae infection.

OBJECTIVES: To determine the presence and genotypic macrolide susceptibility of Mycoplasma amphoriforme, and the presence of Ureaplasma spp. and Mycoplasma fermentans among clinical samples from England previously investigated for Mycoplasma pneumoniae. METHODS: Quantitative and conventional PCR methods were used to retrospectively screen a collection of 160 clinical samples previously submitted to Public Health England (PHE) for the detection of M. pneumoniae between October 2016 and December 2017. Samples which were positive for M. amphoriforme DNA were further investigated for mutations associated with genotypic macrolide resistance by sequencing domain V of the 23s rRNA. RESULTS: M. amphoriforme was detected in 10/160 samples (6.3%), Ureaplasma parvum was detected in 4/160 samples (2.5%), and M. fermentans was not detected in any samples (0/160). Of the nine individuals (two samples were from the same patient) in which M. amphoriforme was detected, eight were male (age range 10-60 years) and one was female (age range 30-40 years). One individual with cystic fibrosis was positive for both M. amphoriforme and U. parvum. All M. amphoriforme DNA was genotypically susceptible to macrolides. CONCLUSIONS: Mycoplasma amphoriforme was found in clinical samples, including lower respiratory tract samples of patients with pneumonia. In the absence of other respiratory pathogens, these data suggest a potential role for this organism in human disease, with no evidence of acquired macrolide resistance. Ureaplasma parvum was detected in cerebrospinal fluid and respiratory tract samples. These data suggest that there is a need to consider these atypical respiratory pathogens in future diagnostic investigations.

Development of an information leaflet and diagnostic flow chart to improve the management of urinary tract infections in older adults: a qualitative study using the Theoretical Domains Framework.

BACKGROUND: Urinary tract infections (UTIs), older age, lack of access to health care, and recent antibiotic use are risk factors for Escherichia coli (E. coli) bloodstream infections. AIM: To explore the diagnosis and management of UTIs in primary care to inform the development of an information leaflet, a diagnostic flow chart, and recommendations for other resources. DESIGN & SETTING: The study had a qualitative design and was undertaken in primary care settings and care homes. METHOD: Interviews and focus groups were informed by the Theoretical Domains Framework (TDF) with 31 care home staff, three residents, six relatives, 57 GP staff, and 19 members of the public. An inductive thematic analysis was used and themes were placed in the Behaviour Change Wheel (BCW) to recommend interventions. RESULTS: Care home staff were pivotal for identifying suspected UTI, alerted clinicians to symptoms that influenced prescribing decisions, and reported confusion or behavioural changes as the most common diagnostic sign. Care home staff lacked knowledge about asymptomatic bacteriuria (ASB) and sepsis, and incorrectly diagnosed UTI using urine dipsticks. GP staff used urine dipsticks to rule out UTI and reported that stopping dipsticks would require a culture change, clear protocols, and education about ASB. Many prescribers believed that stopping urine dipstick use should help to reduce antibiotic use. CONCLUSION: A consistent message about ASB and UTI diagnosis and management in older adults should be communicated across the care pathway. Resource development should increase capability, motivation, and opportunity to improve management of suspected UTIs. An educational leaflet for older adults and a diagnostic flow chart for clinicians have been developed, and recommendations for interventions are discussed.

The impact of nursing on patient and organizational outcomes.

The impact of nursing on patient and organizational outcomes has received significant attention from researchers in the past 10 years. Although some research has been based on a theoretical framework, to date, there has not been one, consistent framework that can guide this research. In addition, the frameworks that have been used do not identify nursing as the pivotal concept in the model. The purpose of this article is to identify a framework to guide such research with an emphasis on nursing as the essential concept. Unit culture, nurse staffing, staffing mix, and other variables do not have a direct effect on outcomes. It is only through these variables' influence on the delivery of nursing care that outcomes are affected.

Care coordination and telehealth technology in promoting self-management among chronically ill patients.

With an increasingly complex healthcare system, the need to coordinate the care for chronically ill patient often goes unmet. This results in increased utilization of services at significant costs. In addition, providing patients with the tools to manage their own disease processes over the long term is also lacking in the healthcare environment. The Veterans Health Administration (VHA) approached these challenges by creating a Care Coordination program using technology to promote self management for veterans. Although a relatively new program, the Veterans Integrated Services Network (VISN) 7, has shown substantial gains in both decreasing the use of high cost care, such as emergency department (ED) visits and hospitalizations, as well as improving clinical outcomes with better glycemic control for patients with diabetes and improved lipid management for all patients.