Diagnosing, managing and preventing urinary tract infections in older people with dementia in hospital.

Urinary tract infections (UTIs) are common in older people and are frequently more complicated to diagnose than in younger adults. There are often challenges associated with distinguishing symptomatic UTIs from asymptomatic bacteriuria, particularly in people with cognitive impairment. Older people with dementia are at increased risk of developing a UTI because dementia can lead to voiding issues, impede personal hygiene and increase the need for urinary catheterisation. Furthermore, while a UTI is usually diagnosed based on an individual's physical signs and symptoms, people with dementia may only exhibit signs of sudden altered mental status such as increased confusion, agitation or withdrawal, making diagnosis challenging. This article discusses the main considerations regarding UTIs in people with dementia in hospital and outlines prevention strategies that nurses can implement in their practice.

Asymptomatic bacteriuria: Impact of an antimicrobial stewardship bundle to reduce unnecessary antibiotics in patients without urinary catheters.

PURPOSE: The purpose of this study was to evaluate the effect of an antimicrobial stewardship bundle on the management of asymptomatic bacteriuria (ASB). METHODS: In this quasi-experimental study, patients were selected by retrospective, consecutive sampling of patients with a positive urine culture report in 3 separate groups: preintervention, postdiagnostic intervention, and posteducation. Patients met the prespecified criteria for non-catheter-associated ASB. The diagnostic intervention involved a new urinalysis/urine culture ordering process in place of urinalysis with reflex to urine culture. Additionally, an educational intervention involved pharmacist-led sessions to educate providers with patient cases and guideline-based recommendations. The primary outcome of this study was the difference in the rate of inappropriate management of ASB, defined as the use of antimicrobial agents intended to treat ASB. Secondary outcomes included length of antimicrobial therapy, length of stay, and change in urine culture orders per 1,000 patient-days. RESULTS: A total of 120 patients were included. There was a significant reduction in the inappropriate management of ASB between the preintervention and postdiagnostic intervention groups (P = 0.0349). This was not seen when comparing the postdiagnostic intervention and posteducation groups (P = 0.93). Additionally, there was a significant difference in urinalysis/urine culture ordering between the preintervention and postdiagnostic intervention groups (370 vs 224 urinalysis orders per 1,000 days present, P < 0.0001; 131 vs 54 urine culture orders per 1,000 days present, P < 0.0001). CONCLUSION: An antimicrobial stewardship bundle involving a diagnostic stewardship intervention and pharmacist-led education reduced treatment of ASB in patients without urinary catheters.

A parallel group randomised open blinded evaluation of Acceptance and Commitment Therapy for depression after psychosis: Pilot trial outcomes (ADAPT).

BACKGROUND: Depression is one of the major contributors to poorer quality of life amongst individuals with psychosis and schizophrenia. The study was designed as a Pilot Trial to determine the parameters of a larger, definitive pragmatic multi-centre randomised controlled trial of Acceptance and Commitment Therapy for depression after psychosis (ACTdp) for individuals with a diagnosis of schizophrenia who also meet diagnostic criteria for major depression. METHODS: Participants were required to meet criteria for schizophrenia and major depression. Blinded follow-ups were undertaken at 5-months (end of treatment) and at 10-months (5-months posttreatment). Primary outcomes were depression as measured by the Calgary Depression Scale for Schizophrenia (CDSS) and the Beck Depression Inventory (BDI). RESULTS: A total of 29 participants were randomised to ACTdp + Standard Care (SC) (n=15) or SC alone (n=14). We did not observe significant differences between groups on the CDSS total score at 5-months (Coeff=-1.43, 95%CI -5.17, 2.32, p=0.45) or at 10-months (Coeff=1.8, 95%CI -2.10, 5.69, p=0.36). In terms of BDI, we noted a statistically significant effect in favour of ACTdp+SC at 5-months (Coeff=-8.38, 95%CI -15.49, -1.27, p=0.02) but not at 10-months (Coeff=-4.85, 95%CI -12.10, 2.39, p=0.18). We also observed significant effects on psychological flexibility at 5-months (Coeff=-8.83, 95%CI -14.94, -2.71, p<0.01) but not 10-months (Coeff=-4.92, 95%CI -11.09, 1.25, p=0.11). IMPLICATIONS: In this first RCT of a psychological therapy with depression as the primary outcome, ACT is a promising intervention for depression in the context of psychosis. A further large-scale definitive randomised controlled trial is required to determine effectiveness. TRIAL REGISTRATION: ISRCTN: 33306437.

Improvement and retention of emergency obstetrics and neonatal care knowledge and skills in a hospital mentorship program in Lilongwe, Malawi.

OBJECTIVE: To evaluate whether a hospital-based mentoring program could significantly increase short- and longer-term emergency obstetrics and neonatal care (EmONC) knowledge and skills among health providers. METHODS: In a prospective before-and-after study, 20 mentors were trained using a specially-created EmONC mentoring and training program at Bwaila Hospital in Lilongwe, Malawi. The mentors then trained an additional 114 providers as mentees in the curriculum. Mentors and mentees were asked to complete a test before initiation of the training (Pre-Test), immediately after training (Post-Test 1), and at least 6 months after training (Post-Test 2) to assess written and practical EmONC knowledge and skills. Mean scores were then compared. RESULTS: Scores increased significantly between the Pre-Test and Post-Test 1 for both written (n=134; difference 22.9%, P<0.001) and practical (n=125; difference 29.5%, P<0.001) tests. Scores were still significantly higher in Post-Test 2 than in the Pre-Test for written (n=111; difference 21.0%, P<0.001) and practical (n=103; difference 29.3%, P<0.001) tests. CONCLUSION: A hospital-based mentoring program can result in both short- and longer-term improvement in EmONC knowledge and skills. Further research is required to assess whether this leads to behavioral changes that improve maternal and neonatal outcomes.

Process-experiential/emotion-focused therapy for social anxiety: a Hermeneutic Single-Case Efficacy Design study.

Social Anxiety (SA) is a common and debilitating problem. Although a range of therapies have been applied to treat SA, only a narrow range of these has been researched to date. In this study, Hermeneutic Single Case Efficacy Design (HSCED) was used to investigate Process-Experiential/Emotion-Focused Therapy (PE-EFT) with a socially isolated client with Social Anxiety. Using a combination of qualitative and quantitative data, we constructed a rich case record and a set of documents arguing for and against client change; these were judged by three graduate student peer judges. The judges found the client to have changed substantially over the first 16 sessions of therapy, and PE-EFT was found to have contributed substantially to this change.