Predicting Antibiotic Susceptibility Among Patients With Recurrent Urinary Tract Infection Using a Prior Culture.

PURPOSE: Recurrent cystitis guidelines recommend relying on a local antibiogram or prior urine culture to guide empirical prescribing, yet little data exist to quantify the predictive value of a prior culture. We constructed a urinary antibiogram and evaluated test metrics (sensitivity, specificity, and Bayes' positive and negative predictive values) of a prior gram-negative organism on predicting subsequent resistance or susceptibility among patients with uncomplicated, recurrent cystitis. MATERIALS AND METHODS: We performed a retrospective database study of adults with recurrent, uncomplicated cystitis (cystitis occurring 2 times in 6 months or 3 times in 12 months) from urology or primary care clinics between November 1, 2016, and December 31, 2018. We excluded pregnant females, patients with complicated cystitis, or pyelonephritis. Test metrics were calculated between sequential, paired cultures using standard formulas. RESULTS: We included 597 visits from 232 unique patients wherein 310 (51.2%) visits had a urine culture and 165 had gram-negative uropathogens isolated. Patients with gram-negative uropathogens were mostly females (97%), with a median age of 58.5 years. Our antibiogram found 38.0%, 27.9%, and 5.5% of Escherichia coli isolates had resistance to trimethoprim-sulfamethoxazole, ciprofloxacin, and nitrofurantoin, respectively. Prior cultures (within 2 years) had good predictive value for detecting future susceptibility to first-line agents nitrofurantoin (0.85) and trimethoprim-sulfamethoxazole (0.78) and excellent predictive values (≥0.90) for cefepime, ceftriaxone, cefuroxime, ciprofloxacin, levofloxacin, gentamicin, tobramycin, piperacillin-tazobactam, and imipenem. CONCLUSIONS: Considerable antibiotic resistance was detected among E coli isolates in patients with recurrent, uncomplicated cystitis. Using a prior culture as a guide can enhance the probability of selecting an effective empirical agent.

Participants With Acquired Brain Injury Realized They "Could Still Do Things" After a Yoga Intervention: A Qualitative Descriptive Study.

IMPORTANCE: Occupational therapy practitioners use yoga in practice to achieve holistic care, and the American Occupational Therapy Association has provided guidance on the use of yoga in occupational therapy. For people with acquired brain injury (ABI), however, it is unknown whether yoga affects occupational performance. OBJECTIVE: To explore the perceived impact of an adapted yoga intervention on occupational performance using the Occupational Therapy Practice Framework: Domain and Process (4th ed.; OTPF-4) for participants with ABI. DESIGN: Qualitative descriptive study using virtual, semistructured interviews. An inductive, holistic, open-coding process, followed by a deductive process to map open codes to the OTPF-4. PARTICIPANTS: Nine individuals with ABI were recruited from a yoga intervention study. RESULTS: The theme generated from the data-"Yoga participants with ABI realized that they could still do quite a bit"-was supported by two major categories from the OTPF-4: Occupations and Performance Skills. Participants described improvements in their functional performance (i.e., motor skills, process skills) and how these factors were synergistically connected to their occupational performance (i.e., self-care, leisure). CONCLUSIONS AND RELEVANCE: This study provides novel insight into how functional performance improved so participants could "still do things," such as engaging in occupations. When participants described improved performance skills, they simultaneously described re-engagement with their meaningful occupations. Participants also perceived an improvement in their mind-body connection, which should be further explored in future studies. This study generated original findings about participants' perceptions of an adapted yoga intervention as they relate to the OTPF-4. Plain-Language Summary: This study reports individuals' perceptions of their re-engagement with occupations and changes in occupational performance skills after participating in an adaptive yoga intervention. We highlight the distinct contribution that adaptive yoga-an intervention modality that can be used by occupational therapy practitioners-may have, using the OTPF-4 to connect the participants' perceptions about their improvements in occupational performance.

All-electrical monitoring of bacterial antibiotic susceptibility in a microfluidic device.

The lack of rapid antibiotic susceptibility tests adversely affects the treatment of bacterial infections and contributes to increased prevalence of multidrug-resistant bacteria. Here, we describe an all-electrical approach that allows for ultrasensitive measurement of growth signals from only tens of bacteria in a microfluidic device. Our device is essentially a set of microfluidic channels, each with a nanoconstriction at one end and cross-sectional dimensions close to that of a single bacterium. Flowing a liquid bacteria sample (e.g., urine) through the microchannels rapidly traps the bacteria in the device, allowing for subsequent incubation in drugs. We measure the electrical resistance of the microchannels, which increases (or decreases) in proportion to the number of bacteria in the microchannels. The method and device allow for rapid antibiotic susceptibility tests in about 2 h. Further, the short-time fluctuations in the electrical resistance during an antibiotic susceptibility test are correlated with the morphological changes of bacteria caused by the antibiotic. In contrast to other electrical approaches, the underlying geometric blockage effect provides a robust and sensitive signal, which is straightforward to interpret without electrical models. The approach also obviates the need for a high-resolution microscope and other complex equipment, making it potentially usable in resource-limited settings.

Optimal Urine Culture Diagnostic Stewardship Practice-Results from an Expert Modified-Delphi Procedure.

BACKGROUND: Urine cultures are nonspecific and often lead to misdiagnosis of urinary tract infection and unnecessary antibiotics. Diagnostic stewardship is a set of procedures that modifies test ordering, processing, and reporting in order to optimize diagnosis and downstream treatment. In this study, we aimed to develop expert guidance on best practices for urine culture diagnostic stewardship. METHODS: A RAND-modified Delphi approach with a multidisciplinary expert panel was used to ascertain diagnostic stewardship best practices. Clinical questions to guide recommendations were grouped into three thematic areas (ordering, processing, reporting) in practice settings of emergency department, inpatient, ambulatory, and long-term care. Fifteen experts ranked recommendations on a 9-point Likert scale. Recommendations on which the panel did not reach agreement were discussed during a virtual meeting, then a second round of ranking by email was completed. After secondary review of results and panel discussion, a series of guidance statements was developed. RESULTS: One hundred and sixty-five questions were reviewed. The panel reaching agreement on 104, leading to 18 overarching guidance statements. The following strategies were recommended to optimize ordering urine cultures: requiring documentation of symptoms, sending alerts to discourage ordering in the absence of symptoms, and cancelling repeat cultures. For urine culture processing, conditional urine cultures and urine white blood cell count as criteria were supported. For urine culture reporting, appropriate practices included nudges to discourage treatment under specific conditions and selective reporting of antibiotics to guide therapy decisions. CONCLUSIONS: These 18 guidance statements can optimize use of urine cultures for better patient outcomes.

Early Convalescent Plasma Therapy and Mortality Among US Veterans Hospitalized With Nonsevere COVID-19: An Observational Analysis Emulating a Target Trial.

BACKGROUND: Early convalescent plasma transfusion may reduce mortality in patients with nonsevere coronavirus disease 2019 (COVID-19). METHODS: This study emulates a (hypothetical) target trial using observational data from a cohort of US veterans admitted to a Department of Veterans Affairs (VA) facility between 1 May and 17 November 2020 with nonsevere COVID-19. The intervention was convalescent plasma initiated within 2 days of eligibility. Thirty-day mortality was compared using cumulative incidence curves, risk differences, and hazard ratios estimated from pooled logistic models with inverse probability weighting to adjust for confounding. RESULTS: Of 11 269 eligible person-trials contributed by 4755 patients, 402 trials were assigned to the convalescent plasma group. Forty and 671 deaths occurred within the plasma and nonplasma groups, respectively. The estimated 30-day mortality risk was 6.5% (95% confidence interval [CI], 4.0%-9.7%) in the plasma group and 6.2% (95% CI, 5.6%-7.0%) in the nonplasma group. The associated risk difference was 0.30% (95% CI, -2.30% to 3.60%) and the hazard ratio was 1.04 (95% CI, .64-1.62). CONCLUSIONS: Our target trial emulation estimated no meaningful differences in 30-day mortality between nonsevere COVID-19 patients treated and untreated with convalescent plasma. Clinical Trials Registration. NCT04545047.

What Is the Primary Driver of Preoperative Vancomycin Use? It's Not Methicillin-resistant Staphylococcus aureus-or Allergy.

Factors driving vancomycin surgical prophylaxis are poorly understood. In a national Veterans Affairs cohort with manually validated data, surgical specialty (cardiac, orthopedics) and perception of high facility methicillin-resistant Staphylococcus aureus (MRSA) prevalence-not MRSA colonization-were the primary drivers of prescribing. A ß-lactam allergy was the second most common reason. These data may inform perioperative stewardship.

How Testing Drives Treatment in Asymptomatic Patients: Level of Pyuria Directly Predicts Probability of Antimicrobial Prescribing.

BACKGROUND: Urinalysis is a readily available test often used for screening. Pyuria is a common finding in asymptomatic patients; however, it is unknown how often identification of pyuria in the absence of confirmatory cultures leads to antimicrobial prescribing. The objective of this study was to measure the association between pyuria and antimicrobial initiation during the perioperative period and assess harms versus benefits of treatment. METHODS: A retrospective cohort of preoperative patients within the national healthcare system during the period 1 October 2008-30 September 2013 who had a urinalysis performed during the 30-day preoperative period was created; patients with positive urine cultures were excluded. The primary exposure was pyuria on preoperative urinalysis. The primary outcome was antimicrobial initiation. Secondary outcomes included postoperative surgical site (SSI), urinary tract (UTI), and Clostridioides difficile infections. Trend and logistic regression analyses were performed. RESULTS: Among 41 373 patients, 3617 had pyuria. 887 (24.5%) patients with pyuria received antimicrobials versus 1918 (5.1%) patients without pyuria. As the degree of pyuria increased, the odds of receiving antimicrobials also increased linearly (low, 14.7%; moderate, 24.0%; high pyuria, 37.4%). Preoperative pyuria was associated with postoperative C. difficile infections (aOR, 1.7; 95% CI, 1.2-2.4); risk was higher in patients who received antimicrobials (aOR, 2.4; 1.7-3.4). Pyuria was not associated with SSI but was associated with increases in UTI after orthopedic and vascular procedures; this risk was not mitigated by antimicrobial therapy. CONCLUSIONS: Urine screening during the preoperative period is a low-value intervention that increases antimicrobial exposure but does not improve postoperative 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.

Clostridium difficile Screening for Colonization During an Outbreak Setting.

A rapidly deployed ward-based screen and isolate initiative for Clostridium difficile carriers during an outbreak averted 5 of 10 expected hospital-acquired infections without identified harms. Each infection avoided required screening 197 and isolating 4.4 patients. Targeted C. difficile screening resulted in outbreak mitigation.

Urinary Tract Infection.

Urinary tract infections (UTIs) are common in both inpatient and outpatient settings. This article provides an evidence-based, clinically relevant overview of management of UTIs, including screening, diagnosis, treatment, and prevention. Conditions covered include acute cystitis (both uncomplicated and complicated), catheter-associated UTI, and asymptomatic bacteriuria in both women and men.

Electronic Consultations (E-consults): Advancing Infectious Disease Care in a Large Veterans Affairs Healthcare System.

The impact of e-consults on total consultative services was evaluated. After implementing infectious diseases e-consults within an electronically integrated healthcare system, consultation volume increased. As compared with face-to-face consultations, e-consults were more often related to antimicrobial guidance and were requested by off-site providers. E-consults increased the breadth and volume of total consults.

Risk of surgical site infection, acute kidney injury, and Clostridium difficile infection following antibiotic prophylaxis with vancomycin plus a beta-lactam versus either drug alone: A national propensity-score-adjusted retrospective cohort study.

BACKGROUND: The optimal regimen for perioperative antimicrobial prophylaxis is controversial. Use of combination prophylaxis with a beta-lactam plus vancomycin is increasing; however, the relative risks and benefits associated with this strategy are unknown. Thus, we sought to compare postoperative outcomes following administration of 2 antimicrobials versus a single agent for the prevention of surgical site infections (SSIs). Potential harms associated with combination regimens, including acute kidney injury (AKI) and Clostridium difficile infection (CDI), were also considered. METHODS AND FINDINGS: Using a multicenter, national Veterans Affairs (VA) cohort, all patients who underwent cardiac, orthopedic joint replacement, vascular, colorectal, and hysterectomy procedures during the period from 1 October 2008 to 30 September 2013 and who received planned manual review of perioperative antimicrobial prophylaxis regimen and manual review for the 30-day incidence of SSI were included. Using a propensity-adjusted log-binomial regression model stratified by type of surgical procedure, the association between receipt of 2 antimicrobials (vancomycin plus a beta-lactam) versus either single agent alone (vancomycin or a beta-lactam) and SSI was evaluated. Measures of association were adjusted for age, diabetes, smoking, American Society of Anesthesiologists score, preoperative methicillin-resistant Staphylococcus aureus (MRSA) status, and receipt of mupirocin. The 7-day incidence of postoperative AKI and 90-day incidence of CDI were also measured. In all, 70,101 procedures (52,504 beta-lactam only, 5,089 vancomycin only, and 12,508 combination) with 2,466 (3.5%) SSIs from 109 medical centers were included. Among cardiac surgery patients, combination prophylaxis was associated with a lower incidence of SSI (66/6,953, 0.95%) than single-agent prophylaxis (190/12,834, 1.48%; crude risk ratio [RR] 0.64, 95% CI 0.49, 0.85; adjusted RR 0.61, 95% CI 0.46, 0.83). After adjusting for SSI risk, no association between receipt of combination prophylaxis and SSI was found for the other types of surgeries evaluated, including orthopedic joint replacement procedures. In MRSA-colonized patients undergoing cardiac surgery, SSI occurred in 8/346 (2.3%) patients who received combination prophylaxis versus 4/100 (4.0%) patients who received vancomycin alone (crude RR 0.58, 95% CI 0.18, 1.88). Among MRSA-negative and -unknown cardiac surgery patients, SSIs occurred in 58/6,607 (0.9%) patients receiving combination prophylaxis versus 146/10,215 (1.4%) patients who received a beta-lactam alone (crude RR 0.61, 95% CI 0.45, 0.83). Based on these associations, the number needed to treat to prevent 1 SSI in MRSA-colonized patients is estimated to be 53, compared to 176 in non-MRSA patients. CDI incidence was similar in both exposure groups. Across all types of surgical procedures, risk of AKI was increased in the combination antimicrobial prophylaxis group (2,971/12,508 [23.8%] receiving combination versus 1,058/5,089 [20.8%] receiving vancomycin alone versus 7,314/52,504 [13.9%] receiving beta-lactam alone). We found a significant association between absolute risk of AKI and receipt of combination regimens across all types of procedures. If the observed association is causal, the number needed to harm for severe AKI following cardiac surgery would be 167. The major limitation of our investigation is that it is an observational study in a predominantly male population, which may limit generalizability and lead to unmeasured confounding. CONCLUSIONS: There are benefits but also unintended consequences of antimicrobial and infection prevention strategies aimed at "getting to zero" healthcare-associated infections. In our study, combination prophylaxis was associated with both benefits (reduction in SSIs following cardiac surgical procedures) and harms (increase in postoperative AKI). In cardiac surgery patients, the difference in risk-benefit profile by MRSA status suggests that MRSA-screening-directed prophylaxis may optimize benefits while minimizing harms in this selected population. More information about long-term outcomes and patient and societal preferences regarding risk of SSI versus risk of AKI is needed to improve clinical decision-making.

Detecting the presence of an indwelling urinary catheter and urinary symptoms in hospitalized patients using natural language processing.

OBJECTIVE: To develop a natural language processing pipeline to extract positively asserted concepts related to the presence of an indwelling urinary catheter in hospitalized patients from the free text of the electronic medical note. The goal is to assist infection preventionists and other healthcare professionals in determining whether a patient has an indwelling urinary catheter when a catheter-associated urinary tract infection is suspected. Currently, data on indwelling urinary catheters is not consistently captured in the electronic medical record in structured format and thus cannot be reliably extracted for clinical and research purposes. MATERIALS AND METHODS: We developed a lexicon of terms related to indwelling urinary catheters and urinary symptoms based on domain knowledge, prior experience in the field, and review of medical notes. A reference standard of 1595 randomly selected documents from inpatient admissions was annotated by human reviewers to identify all positively and negatively asserted concepts related to indwelling urinary catheters. We trained a natural language processing pipeline based on the V3NLP framework using 1050 documents and tested on 545 documents to determine agreement with the human reference standard. Metrics reported are positive predictive value and recall. RESULTS: The lexicon contained 590 terms related to the presence of an indwelling urinary catheter in various categories including insertion, care, change, and removal of urinary catheters and 67 terms for urinary symptoms. Nursing notes were the most frequent inpatient note titles in the reference standard document corpus; these also yielded the highest number of positively asserted concepts with respect to urinary catheters. Comparing the performance of the natural language processing pipeline against the human reference standard, the overall recall was 75% and positive predictive value was 99% on the training set; on the testing set, the recall was 72% and positive predictive value was 98%. The performance on extracting urinary symptoms (including fever) was high with recall and precision greater than 90%. CONCLUSIONS: We have shown that it is possible to identify the presence of an indwelling urinary catheter and urinary symptoms from the free text of electronic medical notes from inpatients using natural language processing. These are two key steps in developing automated protocols to assist humans in large-scale review of patient charts for catheter-associated urinary tract infection. The challenges associated with extracting indwelling urinary catheter-related concepts also inform the design of electronic medical record templates to reliably and consistently capture data on indwelling urinary catheters.

Clinical Management of an Increasing Threat: Outpatient Urinary Tract Infections Due to Multidrug-Resistant Uropathogens.

Urinary tract infections (UTIs) are among the most commonly treated bacterial infections. Over the past decade, antimicrobial resistance has become an increasingly common factor in the management of outpatient UTIs. As treatment options for multidrug-resistant (MDR) uropathogens are limited, clinicians need to be aware of specific clinical and epidemiological risk factors for these infections. Based on available literature, the activity of fosfomycin and nitrofurantoin remain high for most cases of MDR Escherichia coli UTIs. Trimethoprim-sulfamethoxazole retains clinical efficacy, but resistance rates are increasing internationally. Beta-lactam agents have the highest rates of resistance and lowest rates of clinical success. Fluoroquinolones have high resistance rates among MDR uropathogens and are being strongly discouraged as first-line agents for UTIs. In addition to accounting for local resistance rates, consideration of patient risk factors for resistance and pharmacological principles will help guide optimal empiric treatment of outpatient UTIs.

Activity of Fosfomycin against Extended-Spectrum-ß-Lactamase-Producing Uropathogens in Patients in the Community and Hospitalized Patients.

Few oral antibiotics exist for the empirical treatment of extended-spectrum ß-lactamase (ESBL) urinary tract infections (UTI). In this study, we sought to determine the activity of fosfomycin against ESBL-producing uropathogens from patients at 3 Veterans Affairs (VA) facilities between 2010 and 2013. Among the ESBL uropathogens, 19.9% were fosfomycin resistant. Klebsiella species were more likely than Escherichia coli to be resistant (46% versus 4%; P < 0.001). Fosfomycin remains active against a majority of the ESBL uropathogens, although resistance among Klebsiella spp. was higher than that in previous reports.

Two Simple Rules for Improving the Accuracy of Empiric Treatment of Multidrug-Resistant Urinary Tract Infections.

The emergence of multidrug-resistant (MDR) uropathogens is making the treatment of urinary tract infections (UTIs) more challenging. We sought to evaluate the accuracy of empiric therapy for MDR UTIs and the utility of prior culture data in improving the accuracy of the therapy chosen. The electronic health records from three U.S. Department of Veterans Affairs facilities were retrospectively reviewed for the treatments used for MDR UTIs over 4 years. An MDR UTI was defined as an infection caused by a uropathogen resistant to three or more classes of drugs and identified by a clinician to require therapy. Previous data on culture results, antimicrobial use, and outcomes were captured from records from inpatient and outpatient settings. Among 126 patient episodes of MDR UTIs, the choices of empiric therapy against the index pathogen were accurate in 66 (52%) episodes. For the 95 patient episodes for which prior microbiologic data were available, when empiric therapy was concordant with the prior microbiologic data, the rate of accuracy of the treatment against the uropathogen improved from 32% to 76% (odds ratio, 6.9; 95% confidence interval, 2.7 to 17.1; P < 0.001). Genitourinary tract (GU)-directed agents (nitrofurantoin or sulfa agents) were equally as likely as broad-spectrum agents to be accurate (P = 0.3). Choosing an agent concordant with previous microbiologic data significantly increased the chance of accuracy of therapy for MDR UTIs, even if the previous uropathogen was a different species. Also, GU-directed or broad-spectrum therapy choices were equally likely to be accurate. The accuracy of empiric therapy could be improved by the use of these simple rules.

Comparative Effectiveness of Single versus Combination Antibiotic Prophylaxis for Infections after Transrectal Prostate Biopsy.

An increase in fluoroquinolone resistance and transrectal ultrasound-guided prostate (TRUS) biopsy infections has prompted the need for alternative effective antibiotic prophylaxis. We aimed to compare ciprofloxacin and other single-agent therapies to combination therapy for efficacy and adverse effects. Men who underwent a TRUS biopsy within the VA Boston health care system with documented receipt of prophylactic antibiotics periprocedure were eligible for inclusion. Postprocedure infections within 30 days were ascertained by chart review from electronic records, including any inpatient, outpatient, or urgent-care visits. Among 455 evaluable men over a 3-year period, there were 25 infections (5.49%), with sepsis occurring in 2.4%, urinary tract infections (UTI) in 1.54%, and bacteremia in 0.44% of patients. Escherichia coli was the most common urine (89%) and blood (92%) pathogen, with fluoroquinolone resistance rates of 88% and 91%, respectively. Ciprofloxacin alone was associated with significantly more infections than ciprofloxacin plus an additional agent (P = 0.014). Intramuscular gentamicin alone was also significantly associated with a higher infection rate obtained with all other regimens (P = 0.004). Any single-agent regimen, including ciprofloxacin, ceftriaxone, or gentamicin, was associated with significantly higher infection rates than any combination regimen (odds ratio [OR], 4; 95% confidence interval [CI], 1.47, 10.85; P = 0.004). Diabetes, immunosuppressive condition or medication, hospitalization within the previous year, and UTI within the previous 6 months were not associated with infection risk. Clostridium difficile infections were similar. These findings suggest that ciprofloxacin, ceftriaxone, and gentamicin alone are inferior to a combination regimen. Institutions with high failure rates of prophylaxis for TRUS biopsies should consider combination regimens derived from their local data.