Proposing the "Continuum of UTI" for a Nuanced Approach to Diagnosis and Management of Urinary Tract Infections.

PURPOSE: Patients with suspected UTIs are categorized into 3 clinical phenotypes based on current guidelines: no UTI, asymptomatic bacteriuria (ASB), or UTI. However, all patients may not fit neatly into these groups. Our objective was to characterize clinical presentations of patients who receive urine tests using the "continuum of UTI" approach. MATERIALS AND METHODS: This was a retrospective cohort study of a random sample of adult noncatheterized inpatient and emergency department encounters with paired urinalysis and urine cultures from 5 hospitals in 3 states between January 01, 2017, and December 31, 2019. Trained abstractors collected clinical (eg, symptom) and demographic data. A focus group discussion with multidisciplinary experts was conducted to define the continuum of UTI, a 5-level classification scheme that includes 2 new categories: lower urinary tract symptoms/other urologic symptoms and bacteriuria of unclear significance. The newly defined continuum of UTI categories were compared to the current UTI classification scheme. RESULTS: Of 220,531 encounters, 3392 randomly selected encounters were reviewed. Based on the current classification scheme, 32.1% (n = 704) had ASB and 53% (n = 1614) did not have a UTI. When applying the continuum of UTI categories, 68% of patients (n = 478) with ASB were reclassified as bacteriuria of unclear significance and 29% of patients (n = 467) with "no UTI" were reclassified to lower urinary tract symptoms/other urologic symptoms. CONCLUSIONS: Our data suggest the need to reframe our conceptual model of UTI vs ASB to reflect the full spectrum of clinical presentations, acknowledge the diagnostic uncertainty faced by frontline clinicians, and promote a nuanced approach to diagnosis and management of UTIs.

Urinary Tract Infections: Core Curriculum 2024.

Urinary tract infections (UTIs) are some of the most commonly encountered infections in clinical practice. Accurate diagnosis and evidence-based treatment of UTIs will lead to better clinical care for many patients and limit unnecessary antibiotic use. Urinalysis and urine cultures are helpful tools in the diagnosis of UTIs; however, it is important to recognize their limitations. Differentiating between asymptomatic bacteriuria (ASB) and true UTI is important because antibiotics are unnecessary in most nonpregnant patients with ASB and can even potentially cause harm if prescribed. Choice and duration of antibiotics varies across the spectrum of UTI syndromes such as acute uncomplicated cystitis, pyelonephritis, prostatitis, and catheter-associated UTIs. The treatment approach also depends on patients' degree of immunosuppression and their genitourinary anatomy. Therefore, patients with urological obstruction or kidney transplants may require a specialized and multidisciplinary management approach. For individuals prone to frequent UTIs, some preventative measures can be utilized, yet there is often not a "one size fits all" approach.

Bacteriuria in patients with stented ureters: predictors of infection in patients presenting to the hospital and when not to treat.

PURPOSE: Patients with ureteric stents have symptoms that overlap with infection symptoms. Thus, clinicians unnecessarily give antibiotics to stented patients with bacteriuria despite guidelines. In stented patients, little is known about risk factors for developing bacteriuria or urosepsis. The objectives were to identify the frequency and risk factors for developing bacteriuria and urosepsis in patients with stents. METHODS: In this retrospective cohort study, we reviewed patients with ureteric stents placed or exchanged over 1 year. We examined associations between bacteriuria or urosepsis and host risk factors. Univariable and multivariable logistic analyses were performed. RESULTS: Of 286 patients (mean age: 57.2 years), 167 (58.4%) were male. The main stent indications were stone, stricture, cancer and extrinsic compression. The median stented period was 61 days. The frequency of bacteriuria was 59/286 (21%). ASA status 3 and 4 had 5 times the odds of having bacteriuria relative to ASA status 1. Stent duration > 2 months had 5.5 times the odds relative to ≤ 2 months. Urosepsis was infrequent, 13/286 (4.5%). Five patients had bacteraemia. A stent duration over 2 months had nearly 6 times the odds of urosepsis. CONCLUSION: ASA status higher than 2 and stent time greater than 2 months raise the odds of developing bacteriuria. A stent duration longer than 2 months was the only predictor of urosepsis. Though 21% of patients had bacteriuria, 4.5% had urosepsis. Hence, bacteriuria without sepsis should not be treated with antibiotics, thus aiding antimicrobial stewardship.

Decision-making and Treatment Preferences Surrounding Bacteriuria in Nonpregnant Women: A Qualitative Investigation.

INTRODUCTION AND HYPOTHESIS: Best practices suggest nontreatment for asymptomatic bacteriuria in a nonpregnant population, yet there is little literature on patient preference or understanding of asymptomatic bacteriuria treatment. We hypothesize that there might be core factors that affect antibiotic preferences and care-seeking decisions for urinary tract infection and asymptomatic bacteriuria in a postmenopausal population. METHODS: We performed semi-structured interviews with postmenopausal individuals who had been previously treated for at least one patient-reported urinary tract infection. Interviews covered a discussion about their approach to seeking antibiotics for management and knowledge/preferences for asymptomatic bacteriuria management. Two authors independently coded the interviews and identified a set of symptom-related knowledge and experiences that relate to care-seeking and treatment preferences. We then graphically represented a mental model of antibiotic-seeking practices as an influence diagram, illustrating how knowledge and values affect preferences for care. RESULTS: We performed 30 interviews of participants with a mean age of 69.4 (SD 6.4). Among participants, there were four core factors that influence antibiotic seeking for bacteriuria. Participants noted concern for sequelae from untreated bacteria as their primary motivation, but also noted past experiences, information sources, and testing results as themes that affected their mental model surrounding bacteriuria treatment. CONCLUSIONS: The cognitive approach to care-seeking and treatment preference for bacteriuria is influenced by a few central factors. An improved ability to allay concerns either by provider discussions or educational materials are necessary to bridge the gap from the existence of evidence-based guidelines to patient and provider comfort with adherence to these guidelines.

Management of Asymptomatic Bacteriuria and Urinary Tract Infections in Patients With Neurogenic Bladder and Factors Associated With Inappropriate Diagnosis and Treatment.

OBJECTIVE: Inappropriate diagnosis and treatment of asymptomatic bacteriuria (ASB) and urinary tract infection (UTI) are leading causes of antibiotic overuse but have not been well-studied in patients with risks for complicated UTI such as neurogenic bladder (NB). Our aim was to describe ASB and UTI management in patients with NB and assess factors associated with inappropriate management. DESIGN: Retrospective cohort study. SETTING: Four Department of Veteran's Affairs (VA) medical centers. PARTICIPANTS: Adults with NB due to spinal cord injury/disorder (SCI/D), multiple sclerosis (MS), or Parkinson disease (PD) and encounters with an ASB or UTI diagnosis between 2017 and 2018. Clinical and encounter data were extracted from the VA Corporate Data Warehouse and medical record reviews for a stratified sample of 300 encounters from N=291 patients. INTERVENTIONS: None. MAIN OUTCOME MEASURES: Prevalence of appropriate and inappropriate ASB and UTI diagnosis and treatment was summarized. Multivariable logistic regression models assessed factors associated with inappropriate management. RESULTS: N=200 UTI and N=100 ASB encounters were included for the 291 unique patients (SCI/D, 39.9%; MS, 36.4%; PD, 23.7%). Most patients were men (83.3%), >65 years (62%), and used indwelling or intermittent catheterization (68.3%). Nearly all ASB encounters had appropriate diagnosis (98%). 70 (35%) UTI encounters had inappropriate diagnosis, including 55 (27.5%) with true ASB, all with inappropriate treatment. Among the remaining 145 UTI encounters, 54 (27%) had inappropriate treatment. Peripheral vascular disease, chronic kidney disease, and cerebrovascular disease were associated with increased odds of inappropriate management; indwelling catheter (aOR 0.35, P=.01) and Physical Medicine & Rehabilitation provider (aOR 0.29, P<.01) were associated with decreased odds. CONCLUSION: Up to half of UTI encounters for patients with NB had inappropriate management, largely due to inappropriate UTI diagnosis in patients with true ASB. Interventions to improve ASB and UTI management in patients with NB should target complex patients with comorbidities being seen by non-rehabilitation providers.

Impact of altered mental status on antibiotic prescribing and outcomes in hospitalized patients presenting with pyuria.

BACKGROUND: Pyuria is nonspecific and may result in over-treatment of asymptomatic bacteriuria (ASB). The Infectious Diseases Society of America recommends against antibiotic treatment of ASB for most patients including those presenting with altered mental status (AMS). Close observation is recommended over treatment to avoid missing alternative causes of AMS and overuse of antibiotics resulting in adverse events and resistance. OBJECTIVES: The purpose of this study was to evaluate patient outcomes associated with antibiotic treatment of pyuria in patients presenting with AMS at hospital admission without specific urinary tract infection (UTI) symptoms. The primary objective was to compare 30-day readmission rates of patients with pyuria and AMS treated with antibiotics (AMS+Tx) versus those who were not treated (AMS-NoTx). Secondary outcomes included identifying risk factors for antibiotic treatment, comparing alternative diagnoses for AMS, and comparing safety outcomes. METHODS: This retrospective cohort study evaluated adult patients with AMS and pyuria (10 WBC/hpf) admitted between February 1, 2020 and October 1, 2021, in a 350-bed community teaching hospital. Patients with documented urinary symptoms were excluded. Additional exclusion criteria included admission to critical care, history of renal transplant, urological surgery, coinfections, pregnancy, and neutropenia. RESULTS: Two-hundred patients were included (AMS+Tx, n = 162; AMS-NoTx, n=38). There was no difference in 30-day hospital readmission rate for AMS between groups (AMS+Tx 16.7% vs AMS-NoTx 23.7%, P = 0.311). An alternative diagnosis of AMS occurred more frequently when antibiotics were withheld (AMS+Tx 66% vs. AMS-NoTx 86.8%, P = 0.012). Urinalyses showing bacteria (odds ratio 2.52; 95% CI, 1.11-5.731) and positive urine culture (OR 3.36; 95% CI, 1.46-7.711) were associated with antibiotic prescribing. CONCLUSIONS: Inappropriate antibiotic use is common among hospitalized patients presenting with AMS and pyuria; however, treatment of asymptomatic pyuria did not decrease rates of subsequent readmission for AMS or retreatment of symptomatic UTI. Patients who were monitored off antibiotics had higher rates of alternative AMS diagnosis.

Clinical Differences in Dogs with Enterococcal Bacteriuria Compared with Other Bacteriuria: A Retrospective, Case-Control Study.

A retrospective case-control study was performed to determine the clinical differences between dogs with enterococcal bacteriuria (n = 96 cases) and control dogs with any other bacteriuria (n = 288). More dogs with nonenterococcal bacteriuria demonstrated lower urinary tract clinical signs such as hematuria, pollakiuria, and stranguria (40% versus 27%, P = .02). Recessed vulva (odds ratio [OR] 2.5, 95% confidence interval [CI] 1.4-4.2, P < .001), hyperadrenocorticism (OR 0.149, 95% CI 0.004-0.066, P = .03), chronic kidney disease (OR 2.29, 95% CI 1.14-4.51, P = .01), and myelopathy (OR 5.77, 95% CI 3.07-10.82, P < .001) were more common in dogs with enterococcal bacteriuria. Enterococcus spp. cases were more likely to have polymicrobial growth than controls (OR 28.52; 95% CI 12.63-69.62, P ≤ .001). Pugs (OR 7.4, 95% CI 2.6-19.9, P < .001), bearded collies (OR 24.3, 95% CI 2.9-205.5, P = .003), and Saint Bernards (OR 17.3, CI 1.9-154.4, P = .01) had increased odds of enterococcal growth compared with mixed-breed dogs. In the control (but not the case) population, there was an association between resolution of clinical signs and administration of antimicrobials (P = .01). The signalment, clinical signs, comorbidities, and response to therapy in dogs with enterococcal bacteriuria are different from dogs with other bacteriuria.

[Inappropriate treatment of asymptomatic bacteriuria]. / 5 minutes pour apprendre. Traitement problématique d'une bactériurie asymptomatique.

Asymptomatic bacteriuria is frequently encountered in clinical practice and should be treated only in pregnant women and before invasive urological procedures. Inappropriate treatment of asymptomatic bacteriuria is associated with numerous adverse effects including allergic reactions, increased antibiotics resistance and increase risk of Clostridioides difficile infection. Positive urinary culture often leads to antimicrobial treatment, irrespective of urinary symptoms. Therefore, urine analysis and culture should be performed only in symptomatic individuals or in asymptomatic individuals with a clear indication for treatment.

Sulopenem for the Treatment of Complicated Urinary Tract Infections Including Pyelonephritis: A Phase 3, Randomized Trial.

BACKGROUND: Sulopenem is a thiopenem antibiotic being developed for the treatment of multidrug-resistant infections. The availability of both intravenous (IV) and oral formulations will facilitate earlier hospital discharge. METHODS: Hospitalized adults with pyuria, bacteriuria, and signs and symptoms of complicated urinary tract infection (cUTI) were randomized to 5 days of IV sulopenem followed by oral sulopenem etzadroxil/probenecid or 5 days of IV ertapenem followed by oral ciprofloxacin or amoxicillin-clavulanate, depending on uropathogen susceptibility. The primary end point was overall combined clinical and microbiologic response at the test-of-cure visit (day 21). RESULTS: Of 1392 treated patients, 444 and 440 treated with sulopenem and ertapenem, respectively, had a positive baseline urine culture and were eligible for the primary efficacy analyses. Extended-spectrum ß-lactamase-producing organisms were identified in 26.6% of patients and fluoroquinolone-nonsusceptible pathogens in 38.6%. For the primary end point, noninferiority of sulopenem to the comparator regimen was not demonstrated, 67.8% vs 73.9% (difference, -6.1%; 95% confidence interval, -12.0 to -.1%). The difference was driven by a lower rate of asymptomatic bacteriuria in the subgroup of ertapenem-treated patients who stepped down to ciprofloxacin. No substantial difference in overall response was observed at any other time point. Both IV and oral formulations of sulopenem were well-tolerated and compared favorably to the comparator. CONCLUSIONS: Sulopenem followed by oral sulopenem-etzadroxil/probenecid was not noninferior to ertapenem followed by oral step-down therapy for the treatment of cUTIs, driven by a lower rate of asymptomatic bacteriuria in those who received ciprofloxacin. Both formulations of sulopenem were well-tolerated. CLINICAL TRIAL REGISTRATION: NCT03357614.

Current Pyuria Cutoffs Promote Inappropriate Urinary Tract Infection Diagnosis in Older Women.

BACKGROUND: Pre-existing lower urinary tract symptoms (LUTS), cognitive impairment, and the high prevalence of asymptomatic bacteriuria (ASB) complicate the diagnosis of urinary tract infection (UTI) in older women. The presence of pyuria remains the cornerstone of UTI diagnosis. However, >90% of ASB patients have pyuria, prompting unnecessary treatment. We quantified pyuria by automated microscopy and flowcytometry to determine the diagnostic accuracy for UTI and to derive pyuria thresholds for UTI in older women. METHODS: Women ≥65 years with ≥2 new-onset LUTS and 1 uropathogen ≥104 colony-forming units (CFU)/mL were included in the UTI group. Controls were asymptomatic and classified as ASB (1 uropathogen ≥105 CFU/mL), negative culture, or mixed flora. Patients with an indwelling catheter or antimicrobial pretreatment were excluded. Leukocyte medians were compared and sensitivity-specificity pairs were derived from a receiver operating characteristic curve. RESULTS: We included 164 participants. UTI patients had higher median urinary leukocytes compared with control patients (microscopy: 900 vs 26 leukocytes/µL; flowcytometry: 1575 vs 23 leukocytes/µL; P < .001). Area under the curve was 0.93 for both methods. At a cutoff of 264 leukocytes/µL, sensitivity and specificity of microscopy were 88% (positive and negative likelihood ratio: 7.2 and 0.1, respectively). The commonly used cutoff of 10 leukocytes/µL had a poor specificity (36%) and a sensitivity of 100%. CONCLUSIONS: The degree of pyuria can help to distinguish UTI in older women from ASB and asymptomatic controls with pyuria. Current pyuria cutoffs are too low and promote inappropriate UTI diagnosis in older women. Clinical Trials Registration. International Clinical Trials Registry Platform: NL9477 (https://trialsearch.who.int/Trial2.aspx?TrialID=NL9477).

Impact of antibiotic pharmacokinetics in urine on recurrent bacteriuria following treatment of complicated urinary tract infections.

The clinical relevance of bacteriuria following antibiotic treatment of complicated urinary tract infections in clinical trials remains controversial. We evaluated the impact of urine pharmacokinetics on the timing of recurrent bacteriuria in a recently completed trial that compared oral tebipenem pivoxil hydrobromide to intravenous ertapenem. The urinary clearance and urine dwell time of ertapenem were prolonged relative to tebipenem and were associated with a temporal difference in the repopulation of bladder urine with bacteria following treatment, potentially confounding the assessment of efficacy.

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

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

A Systematic Review of Antimicrobial Stewardship Interventions to Improve Management of Bacteriuria in Hospitalized Adults.

OBJECTIVE: To determine whether implementation of antimicrobial stewardship (AMS) interventions improve management of bacteriuria in hospitalized adults. DATA SOURCES: EMBASE, MEDLINE, CINAHL, and Clinical Trials Registries via Cochrane CENTRAL were searched from inception through May 2021. Reference lists of included studies were searched, and Scopus was used to retrieve articles that cited included references. STUDY SELECTION AND DATA EXTRACTION: Randomized and nonrandomized trials, controlled before-after studies, interrupted time-series studies, and repeated measures studies evaluating AMS interventions for hospitalized adult inpatients with bacteriuria were included. Risk of bias was assessed independently by 3 team members and compared. Results were summarized descriptively. DATA SYNTHESIS: The search yielded 5509 articles, of which 13 met inclusion criteria. Most common interventions included education (N = 8) and audit and feedback (N = 5) alone or in combination with other interventions. Where assessed, resource and antimicrobial use primarily decreased and appropriateness of antimicrobial use improved; however, impact on guideline adherence was variable. All studies were rated as having unclear or serious risk of bias. This review summarizes and assesses the quality of evidence for AMS interventions to improve the management of bacteriuria. Results provide guidance to both AMS teams and researchers aiming to develop and/or evaluate AMS interventions for management of bacteriuria. CONCLUSIONS: This review demonstrated benefit of AMS interventions on management of bacteriuria. However, most studies had some risk of bias, and an overall effect across studies is unclear due to heterogeneity in outcome measures.

Incidence and Causative Organisms of Bacteriuria in Children With Cancer: A 9-Year Experience in a Tertiary Pediatric Center.

Although infection is common in patients with cancer, the distribution of causative agents and the proportion of resistant bacteria in patients with urinary tract infection remain unknown. The aim of this study was to describe the incidence, the causative agents, and the proportion of antimicrobial resistance in bacteria cultured from urine of hospitalized children with cancer. A single-center retrospective chart review of patients with cancer admitted between 2012 and 2020 was performed to identify patients with positive urine culture. Overall, 61 (0.9%) of 7107 patients were identified to have positive urine cultures. Among them, 25 patients (41%) had symptomatic bacteriuria. The most common pathogenic bacterium among all patients was Escherichia coli ( E. coli ) (n=15, 25%), followed by Enterococcus sp. (n=14, 23%), Klebsiella sp. (n=12, 20%), and Pseudomonas aeruginosa ( P. aeruginosa ) (n=12, 20%). Extended spectrum ß-lactamases-producing E. coli and Extended spectrum ß-lactamases-producing Klebsiella pneumoniae were detected in 1 patient (2%) and 4 patients (7%), respectively. No multidrug-resistant P. aeruginosa and vancomycin-resistant Enterococcus were detected. The incidence of bacteriuria was found to be low in children with cancer. The distribution of causative agents of bacteriuria in children with solid tumors and hematologic diseases may be different from that in previously healthy children.

Outcome of febrile neutropenic patients treated for bacteriuria in hematology.

INTRODUCTION: Positive urine sample is a frequent finding in post-chemotherapy febrile neutropenia (FN) and can lead to prolonged antibiotic therapy. The aim of this study was to assess the outcome of bacteriuria episodes in FN patients receiving targeted antibiotic therapy. MATERIALS AND METHODS: A multi-centric retrospective study was conducted over a four-year period (2014-2019) on systematic urinalysis. All consecutive first bacteriuria episodes (≤ 2 bacteria with at least ≥ 103 CFU/mL) during FN in hospitalized adult patients for hematological malignancies were included. Relapse and recurrence were defined by fever or urinary tract symptoms (UTS) with the same bacterial subspecies in urine occurring ≤ 7 days and ≤ 30 days, respectively, after antibiotic discontinuation. Mortality rate was determined at 30 days. Targeted antibiotic therapy ≤ 10 days for women and ≤ 14 for men was considered as short course. RESULTS: Among 97 patients, 105 bacteriuria episodes on systematic urinalysis were analyzed; 67.6% occurred in women, 41.9% in AML patients, 17.1% were bacteremic, 14.2% presented with UTS, and 61.9% were treated with short-course antibiotic treatment. One death was reported. In men, no relapse/recurrence was noted, even in the short-course antibiotic group. In women, 2.8% of episodes treated with short-course antibiotic led to relapse or recurrence. CONCLUSIONS: Relapse, recurrence, and mortality were uncommon events in FN patients experiencing bacteriuria episode, whatever the antibiotic duration. To distinguish asymptomatic bacteriuria from infection remained challenging in women. In men, systematic urinalysis at onset of FN could be useful.

A double-blinded randomized placebo-controlled non-inferiority trial protocol for postoperative infections associated with canine pyometra.

BACKGROUND: Pyometra is a common infectious condition, especially in elderly bitches. In addition to an infected uterus, dogs may have concurrent urinary tract infection (UTI). The preferred treatment is surgical removal of the ovaries and uterus, whereupon the general prognosis is excellent. In addition, antimicrobial therapy is frequently prescribed for postoperative treatment. However, no research exists on the benefit of postoperative antimicrobial treatment in uncomplicated canine pyometra. Antimicrobial resistance has become a major challenge in treatment of bacterial infections. Diminishing overuse of antimicrobial agents is essential for controlling the development of antimicrobial resistance in both animals and humans. METHODS: This double-blinded, randomized, placebo-controlled two-arm clinical trial is designed to compare the incidence of postoperative infections associated with surgical treatment of uncomplicated pyometra followed by two different treatment protocols. For the study, 150 dogs presenting with an uncomplicated pyometra and that are to undergo surgical treatment will be recruited. Dogs with body weight < 3 or > 93 kg, complicated pyometra, primary disease increasing the risk of infection, or immunosuppressive medication will be excluded. All dogs will receive one dose of sulfadoxine-trimethoprim intravenously as an antimicrobial prophylaxis. Postoperatively, dogs will be randomized to receive either a five-day course of placebo or an active drug, sulfadiazine-trimethoprim orally. During the surgery microbiological samples will be taken from urine and uterine content. The follow-up includes a control visit in 12 days and an interview of the owner 30 days after surgery. If bacteriuria is detected at the time of surgery, a urinary sample will be cultured for bacterial growth at the control visit. The primary outcome is the incidence of a postoperative surgical site infection (SSI), and the secondary outcome is the occurrence of clinical UTI with bacteriuria. Intention-to-treat and per-protocol analyses will be performed to compare outcome incidences between the treatment groups. DISCUSSION: Research-based evidence is necessary to create treatment guidelines for judicious use of antimicrobials. The goals of this study are to provide evidence for reducing the use of antimicrobials and targeting the treatment to patients proven to benefit from it. Publishing the trial protocol will increase transparency and promote open science practices.

Pathophysiologic Insights into the Transition from Asymptomatic Bacteriuria to Urinary Tract Infection.

PURPOSE OF REVIEW: Asymptomatic bacteriuria (ASB) can be found in the general population but it is more common in catheterized patients. Some patients develop urinary tract infections (UTI) and others stay asymptomatic throughout time. The scientific community lacks a pathophysiologic explanation of why asymptomatic bacteriuria stays asymptomatic most of the time, and why and how it sometimes transitions to UTI. In an attempt to bridge this gap in knowledge, a summary of the current literature is conducted on the pathophysiologic differences between ASB and UTI, beyond their clinical differences. RECENT FINDINGS: ASB and UTI cannot be differentiated just by their phylogroup or number of virulence factors. The difference may be in their metabolism gene expression. The literature lacks a pathophysiological explanation of the transition from ASB to UTI, and recent discoveries suggest that metabolic gene expression may hold the key.

Treatment of Asymptomatic Bacteriuria after Kidney Transplantation: A Systematic Review and Meta-Analysis of Randomized Controlled Trials.

Background and Objectives: Asymptomatic bacteriuria (ASB) is prevalent in kidney transplant recipients (KTRs) and is hypothesized to heighten the risk of subsequent urinary tract infections (UTIs). Whether antibiotic treatment of ASB in KTRs is beneficial has not been elucidated. Materials and Methods: We carried out a systematic review and meta-analysis of all randomized controlled trials (RCTs) and quasi-RCTs that examined the merits of managing asymptomatic bacteriuria in KTRs. The primary outcomes were rates of symptomatic urinary tract infections (UTIs) and antimicrobial resistance. Results: Five studies encompassing 566 patients were included. No significant difference in symptomatic UTI rates was found between antibiotics and no treatment groups (relative risk (RR) 1.05, 95% confidence interval (CI) = 0.78-1.41), with moderate heterogeneity (I2 = 36%). Antibiotic treatment was found to present an uncertain risk for the development of drug-resistant strains (RR = 1.51, 95% CI = 0.95-2.40, I2 = 0%). In all trials, no significant difference between study arms was demonstrated regarding patient and graft outcomes, such as graft function, graft loss, hospitalization due to UTI, all-cause mortality, or acute rejection. Conclusions: The practice of screening and treating kidney transplant patients for asymptomatic bacteriuria does not curtail the incidence of future symptomatic UTIs, increase antimicrobial resistance, or affect graft outcomes. Whether early treatment of ASB after kidney transplantation (<2 months) is beneficial requires more RCTs.

OCCURRENCE OF AMINOGLYCOSIDES RESISTANCE GENES ACC(6)-IB AND ACC(3)-II AMONG GRAM-NEGATIVE ISOLATES CAUSING URINARY TRACT INFECTION IN PEDIATRIC PATIENTS, NAJAF, IRAQ.

OBJECTIVE: The aim: The aim of the study was to detect the antimicrobial susceptibility patterns and frequency of aminoglycosides resistance genes of Gram-negative bacteria isolated from pediatric patient with UTI. PATIENTS AND METHODS: Materials and methods: The study has been performed with a total of 500 urine specimens collected from pediatric patients under the age of 18 year suspected with UTI, admitted to hospitals in Al-Najaf province/Iraq during the period from November 2018 to March 2019. RESULTS: Results: A total of 500 urine specimens had been tested, 120 (24%) had signifficant bacteriuria, while there 380 (76%) had non-signi!cant bacteriuria. Escherichia coli represent about 70 (68.2%) followed by followed by 23 (22.5%) K. pneumoniae, 5 (4.9%) P. aeruginosa, 2 (1.9%) Proteus spp., 1 (0.9%) Enterobacter spp. and 1 (0.9%) Oligella uratolytic. The antimicrobial susceptibility profile of 102 Gram-negative isolates, revealed that 59 (58%) were multidrug resistant (MDR) and 38(37%) were extensive drug resistant (XDR). The PCR results of aminoglycosides resistance showing that 23 (74.1%) Gram-negative isolates had acc(6')-Ib gene and 12 (38.7%) Gram-negative isolates acc(3')-II gene. CONCLUSION: Conclusions: A high frequency of multi-drug resistance and extensive-drug resistance of isolates were recognized, and an alarming percentage of amino-glycosides resistance to acc(6')-Ib and acc(3')-II.

BACTERIAL PROFILE, ANTIMICROBIAL RESISTANCE, AND FACTORS ASSOCIATED WITH URINARY TRACT INFECTION AMONG PREGNANT WOMEN AT HOSANNA TOWN HEALTH FACILITIES, CENTRAL ETHIOPIA.

Urinary tract infection in pregnancy is a common microbial infection. Antimicrobial resistance among uropathogens is becoming a major health problem worldwide. The antimicrobial agents used to manage urinary tract infections during pregnancy should be carefully chosen. Therefore, this study aimed to determine the bacterial profile, antibiotic susceptibility pattern, and factors associated with urinary tract infection among pregnant women at Hosanna town public health facilities. A facility-based cross-sectional study was conducted from March to August 2022 on a total of 312 pregnant women who attended antenatal care at Hosanna Town public health facilities. Sociodemographic, clinical data, and related information were collected by using a pre-tested questionnaire. In addition, mid-stream urine specimens were collected from study participants. Bacterial pathogens were identified by standard bacteriological techniques. Antibiotic susceptibility testing was performed by using the Kirby Bauer disk diffusion method. The data were analyzed by using SPSS version 25. Chi-square and odds ratios were calculated and a P-value≤0.05 at a 95% confidence interval was considered statistically significant. The results were presented with words and tables. Of a total of pregnant women, 59/312(18.9%) (95% CI: 14.7-23.7) were found to have significant bacteriuria. The predominant isolates were Escherichia coli (E. coli) 22(34.4%), followed by coagulase-negative staphylococci (CoNS) 10(15.6%), Staphylococci aureus (S. aureus) 7(10.9%), and Klebsiella pneumoniae (K. pneumoniae) 6(9.4%). Overall, 78.1% of these isolates were multidrug-resistant (MDR). Gram-negative bacteria were susceptible to meropenem (97.6%), gentamicin (85.7%), nitrofurantoin (82.1%), ciprofloxacin (73.8%), amoxicillin-clavulanic acid (73.8%) and ceftriaxone (71.8%), but highly resistant to ampicillin (95.5%), trimethoprim-sulfamethoxazole (74.4%), doxycycline (71.8%), cefuroxime (69.2%), and cephalexin (69.2%). The gram-positive bacteria were susceptible to gentamicin (86.4%), erythromycin (81.8%), and nitrofurantoin (77.3%): whereas they showed a high level of resistance to penicillin (72.7%), doxycycline (54.5%), trimethoprim-sulfamethoxazole (52.9%), and cefoxitin (52.9%). No formal education for the participant (AOR: 2.86, 95% CI: 1.03-7.98, p=0.044), family monthly income <1500 birr (AOR: 3.19, 95% CI: 1.48-6.89, p=0.003), and previous history of UTI (AOR: 4.52, 95% CI: 2.04-10.03, p=0.001) were significantly associated with bacteriuria. This study revealed a high prevalence of bacterial urinary tract infection among pregnant women and low susceptibility to ampicillin, trimethoprim-sulfamethoxazole, cefuroxime, and cephalexin. Therefore, regularly, culture-based bacterial identification and antibiotic susceptibility testing should be performed. Alternatively, empiric antibiotic therapy should consider the prevalence of antibiotic-resistant uropathogens and the factor that may increase the urinary tract infection occurrence due to multi-drug resistant uropathogens.