Evidence-Based Management of Urinary Tract Infections Across the Lifespan: Current Update

Urinary tract infections (UTIs) are common in a busy primary care setting, accounting for approximately 7 million office visits annually. These infections affect all ages and both sexes, with the highest prevalence in women. The key to management of the uncomplicated UTI depends on the correct diagnosis and pharmacologic agent. Other variables to consider when treating UTIs are uropathogen resistance patterns, patient population, and duration of therapy to name a few. This article presents an evidence-based approach to the diagnosis and treatment of UTIs across the lifespan.     

Incidence and risk factors for acquiring nosocomial urinary tract infection in the critically ill

PURPOSE: A urinary tract infection (UTI) is the most common hospital-acquired infection. However, the epidemiology of intensive care unit (ICU)-acquired UTIs is not well defined. The objective of this study was to describe the incidence, risk factors, and clinical outcomes of ICU-acquired UTIs. MATERIALS AND METHODS: All patients admitted to adult multidisciplinary ICUs in the Calgary Health Region (CHR, population approximately 1 million) during May 1, 1999 to April 30, 2000 were studied using a cohort design. RESULTS: A total of 1,158 admissions to a CHR ICU were 48 hours in duration or more. A total of 111 episodes of ICU-acquired UTI (defined as >10(5) CFU/mL of 1 or 2 organisms >48 hours after ICU admission) occurred in 105 (9%) patients and 5 (0.4%) had ICU-acquired bacteremic/fungemic UTIs for incidences of 11.3 and 0.5 UTIs per 1,000 ICU days, respectively. Significant independent risk factors for developing an ICU-acquired UTI as determined by a logistic regression model were female gender (adjusted odds ratio [OR(adj)], 2.31; 95% confidence interval [CI], 1.48-3.59) and natural logarithmic transformation of ICU length of stay (OR(adj), 3.96; 95% CI, 3.02-5.17). No differences in admitting vital signs, routine blood tests, APACHE II and TISS scores, or overall hospital mortality rate were observed among patients who developed an ICU-acquired UTI as compared with those who did not. The most common UTI etiologies were Enterococcus spp. (24%), Candida albicans (21%), and Escherichia coli (15%). Only 4 (3%) of the organisms were highly antibiotic resistant. CONCLUSIONS: Nosocomial UTIs develop commonly in the critically ill and women and those with an extended ICU stay are at increased risk. Although ICU-acquired UTIs are markers of morbidity, they do not significantly increase mortality.     

Urinary tract infection: traditional pharmacologic therapies

Urinary tract infections (UTIs) are common bacterial infections, particularly in women. Antimicrobial therapy is seldom indicated for asymptomatic infection, but antimicrobial therapy is usually indicated for amelioration of symptoms. Management of acute uncomplicated UTI (cystitis) is generally straightforward, with a predictable distribution of uropathogens isolated. First-line treatment of acute uncomplicated UTI has traditionally involved a 3-day regimen of trimethoprim-sulfamethoxazole (TMP-SMX) or TMP alone for patients with sulfa allergies. Increasing resistance among community-acquired Escherichia coli to TMP-SMX worldwide has led to a reassessment of the most appropriate empiric therapy for these infections. Alternative first-line agents include the fluoroquinolones, nitrofurantoin, and fosfomycin.Factors to be considered in the selection of appropriate antimicrobial therapy include pharmacokinetics, spectrum of activity of the antimicrobial agent, resistance prevalence for the community, potential for adverse effects, and duration of therapy. Ideal antimicrobial agents for UTI management have primary excretion routes through the urinary tract to achieve high urinary drug levels. In addition, there are special considerations in the management of UTI among selected populations, including postmenopausal and pregnant women, and for women with frequent recurrent UTIs.     

Headache in United States emergency departments: demographics, work-up and frequency of pathological diagnoses

Headache is a common complaint in the emergency department (ED). In order to examine headache work-ups and diagnoses across the USA, we queried a representative sample of adult ED visits (the National Hospital Ambulatory Medical Care Survey) for the years 1992-2001. Headache accounted for 2.1 million ED visits per year (2.2% of visits). Of the 14% of patients who underwent neuroimaging, 5.5% received a pathological diagnosis. Of the 2% of patients who underwent lumbar puncture, 11% received a pathological diagnosis. On multivariable analysis, a decreased rate of imaging was noted for patients without private insurance [odds ratio (OR) 0.61, confidence interval (CI) 0.44, 0.86] and for those presenting off-hours (OR 0.55, CI 0.39, 0.77). Patients over 50 were more likely to receive a pathological diagnosis (OR 3.3, CI 1.2, 9.3). In conclusion, clinicians should ensure that appropriate work-ups are performed regardless of presentation time or insurance status, and be vigilant in the evaluation of older patients.     

Urinary tract infections in women

Urinary tract infections in female patients are exceedingly common. One third of all women with an initial UTI demonstrate recurrence, and one third of those recurrences are in the first 6 months. The potential morbidity of RUTIs is high, especially in infants, the elderly, and pregnant patients. Uropathogenic bacteria reside in the rectal vault, colonize the vagina, and then ascend per the urethra into the bladder. These bacteria avidly adhere to uroepithelial cells using pili and can further ascend to the kidneys. Empiric treatment of an initial uncomplicated UTI is acceptable, but recurrences warrant a urine culture and possible radiographic evaluation. Fluoroquinolones are now first-line medications for UTIs, except in geographic areas where resistance to TMP-SMX is still low. Response to therapy should govern the need for additional treatment. Certain motivated patients with three or more UTIs per year should be considered for prophylaxis therapy.     

Magnitude of national ED visits and resource utilization by the uninsured

Background

For nearly 51 million persons in the United States who lack health care insurance, the emergency department (ED) functions as a safety net where no patient is denied care based on ability to pay, and much public rhetoric has characterized ED utilization by uninsured patients. We estimated national ED utilization by uninsured patients and compared uninsured and insured ED patients in terms of demographics, diagnostic testing, disposition and final diagnoses.

Methods

We analyzed data from the National Hospital Ambulatory Medical Care Survey (2006-2009) stratified by insurance status. Demographic data, diagnoses, testing, and procedures performed in the ED were tabulated for each visit. Weighted percentages provided by National Hospital Ambulatory Medical Care Survey were used to estimate national rates for each variable, and multivariate models were constructed for predicting testing, procedures, and admission.

Results

The 135 085 ED visits represent 475 million patients visits, of which 78.9 million (16.6%) were uninsured. Compared with insured patients, uninsured patients were more often male (51.1% vs 44.3%) and younger (age 18-44 years, 66.2% vs 35.4%). Uninsured patients had lower rates of circulatory/cardiovascular (7.5% vs 4.1%) and respiratory diagnoses (14.6% vs 11.8%). Uninsured patients had fewer diagnostic tests and procedures and fewer hospital admissions than those with insurance. In our multivariate models, insurance status was predictive of testing and procedures but not hospital admission.

Conclusions

Uninsured patients account for approximately 20 million or 1 in 6 ED visits annually in the United States and have differences in demographics, diagnoses, and ED utilization patterns from those with insurance.     

Emergency Department Utilization in the United States and Ontario, Canada

Objectives: The current crisis in the emergency care system is characterized by worsening emergency department (ED) overcrowding. Lack of health insurance is widely perceived to be a major contributing factor to ED overcrowding in the United States. This study aimed to compare ED visit rates in the United States and Ontario, Canada, according to demographic and clinical characteristics.
Methods: This was a cross sectional study consisting of a nationally representative sample of 40,253 ED visits included in the 2003 National Hospital Ambulatory Medical Care Survey in the United States, and all ED visits recorded during 2003 by the National Ambulatory Care Reporting System in Ontario, Canada. The main outcome was the number of ED visits per 100 population per year.
Results: The annual ED visit rate in the United States was 39.9 visits (95% confidence interval = 37.2 to 42.6) per 100 population, virtually identical to the rate in Ontario, Canada (39.7 visits per 100 population). In both the United States and Ontario, Canada, those aged 75 years and older had the highest ED visit rate and women had a slightly higher ED visit rate than men. The most common discharge diagnosis was injury/poisoning, accounting for 25.6% of all ED visits in the United States and 24.7% in Ontario, Canada. Overall, 13.9% of ED patients in the United States were admitted to hospitals, compared with 10.5% in Ontario, Canada.
Conclusions: ED visit rates and patterns are similar in the United States and Ontario, Canada. Differences in health insurance coverage may not have a substantial impact on the overall utilization of emergency care.     

ED visits by older adults for ambulatory care-sensitive and supply-sensitive conditions

OBJECTIVES: The aim of this study was to examine the effect of advanced age on ED outcomes, including hospitalization for any reason, ambulatory care-sensitive hospitalizations (ACSHs), and supply-sensitive hospitalizations. METHODS: A secondary data analysis of the National Hospital Ambulatory Care Survey was conducted. National estimates of patient visits were obtained using available sampling weights from National Hospital Ambulatory Care Survey, and population estimates were calculated using estimates published by the US Census Bureau. RESULTS: Older adults made 48 million patient visits to ED between 2000 and 2002. Overall, 20.3% was for an ambulatory care-sensitive condition, yielding 5 million ACSH, whereas 62% was for a supply-sensitive condition, yielding 9.5 million supply-sensitive hospitalizations. Residents from nursing homes and patients aged 85 years or older were more likely to be hospitalized for any reason, for ACSH, and for supply-sensitive conditions. CONCLUSIONS: Further research is needed to understand how comorbidity contributes to increasing ED and hospital use among older adults.     

Impact of national low back pain guidelines on clinical practice

OBJECTIVES: The purpose of this study was to assess the impact of the 1994 Agency for Health Research and Quality (AHRQ) clinical practice guidelines on the management of acute low back pain. METHODS: From the National Ambulatory Medical Care Service database, the authors abstracted data on patients being seen in primary care settings, presenting with low back pain as their primary reason for visit, and aged between 20 and 55 years. Patients with an inflammatory or secondary diagnosis to explain their back pain were excluded. Using the sampling weights assigned by the National Ambulatory Medical Care Service, we assessed the medications prescribed, referrals for physiotherapy, and radiography usage for 3 years before (1991 to 1993) and after (1995 to 1997) release of the back pain guidelines. RESULTS: During these 6 years, more than 10 million ambulatory office visits were available for analysis, 5.2 million visits between 1991 to 1993 and 5.0 million visits between 1995 to 1997. The most common diagnosis was lumbago, present in 21% of these visits. Acetaminophen use increased 20-fold from 0.1 to 2%, nonsteroidal use increased from 40 to 43%, muscle relaxant use decreased from 29 to 20%, radiography ordering increased slightly from 15.4 to 19.4%, and physical therapy referrals declined from 27 to 22%. There was no evidence of a trend toward increased compliance with the AHRQ guidelines over time. CONCLUSIONS: The AHRQ clinical practice guidelines for the management of acute low back pain had a modest impact on physician behavior, increasing the use of acetaminophen and nonsteroidals and decreasing the use of muscle relaxants and physical therapy referrals.     

Summary statistics for acute cardiac ischemia and chest pain visits to United States EDs, 1995-1996.

In this article we describe characteristics of emergency encounters for patients with a diagnosis of acute cardiac ischemia (ACI) and for patients with chest pain complaints. Data are from the National Hospital Ambulatory Medical Care Survey, which includes abstracts from the medical records of a national probability sample of visits to emergency departments (ED). Analysis was limited to records of patients 25 years of age and older with a diagnosis of either confirmed or suspected acute myocardial infarction (AMI) or unstable angina pectoris and records with a nontraumatic chest pain complaint. There was an estimated annual average of 1.2 million visits to EDs by patients 25 years and over with a diagnosis of ACI in 1995-1996, an average annual rate of 7.2 visits per 1,000 persons. Visit rates varied by patient's age, race, and gender. Chest pain was a complaint in three-fourths of all ACI visits. There were an estimated 4.6 million annual ED visits where in patients aged 25 years and older had complaints of nontraumatic chest pain, an average annual rate of 27.7 visits per 1,000 persons. ACI accounted for 11% of all chest pain visits, but the probability of the chest pain visit having an ACI diagnosis varied by patient's age and race. There remains a large amount of variation in treatment for suspected and confirmed AMI, and for patients presenting with chest pain to EDs.     

Characteristics of patient visits to nurse practitioners and physician assistants in hospital outpatient departments

Many authors have described differences between nurse practitioners and physician assistants. Most studies have compared physician with nonphysician providers' practice. Few studies have compared nurse practitioners and physician assistants, and none has used a national data base. This exploratory, atheoretical research examined which of the following characteristics predicted patients being seen by nurse practitioners and physician assistants: patient and hospital demographics, diagnosis, diagnostic/screening services, therapeutic services, and disposition of the visit. The data set used for analysis was the 1992 National Hospital Ambulatory Medical Care Survey. Based on a multistage probability design yielding national estimates for patient visits in hospital outpatient settings, the National Hospital Ambulatory Medical Care Survey showed that there were 2,847 weighted patient visits to either nurse practitioners or physician assistants (4.6 million patient visits using national estimates). Results of multivariate logistic regression suggest that nurse practitioners were the most likely nonphysician provider for outpatients receiving more health promotion and counseling (therapeutic) services and for those needing women's and children's services. Outpatients in rural areas predicted visits to physician assistants. As more nonphysician providers enter the work force, the results of this research may assist with understanding the utilization of nurse practitioners and physician assistants in primary care.     

Characteristics and temporal trends of "left before being seen" visits in US emergency departments, 1995-2002

The purpose of this study was to describe nationally representative characteristics and temporal trends in "left before being seen" (LBBS) visits in US emergency departments (EDs). The ED portion of the federal National Hospital Ambulatory Medical Care Survey, 1995-2002, was analyzed. Of the 810.6 million ED visits during the 8-year study period, an estimated 11.4 million (1.41%, 95% confidence interval [CI] 1.30-1.52) had an LBBS disposition. The number and proportion of LBBS visits have increased over time, from 1.1 million visits in 1995 (1.15%, 95% CI 0.95-1.35) to 2.1 million visits in 2002 (1.92%, 95% CI 1.67-2.17). LBBS patients were more likely to be younger, non-White, Hispanic, urban, and uninsured compared to non-LBBS patients. The number and proportion of LBBS visits have increased over time. LBBS visits disproportionately affect vulnerable populations. These findings suggest that recent strains on the US ED system are adversely affecting healthcare quality and access.     

National differences between ED and ambulatory visits for suicidal ideation and attempts and depression

Background

Many suicidal and depressed patients are seen in emergency departments (EDs), whereas outpatient visits for depression remain high.

Study objective

The primary objective of the study is to determine a relationship between the incidence of suicidal and depressed patients presenting to EDs and the incidence of depressed patients presenting to outpatient clinics. The secondary objective is to analyze trends among suicidal patients.

Methods

The National Hospital Ambulatory Medical Care Survey and the National Ambulatory Medical Care Survey were screened to provide a sampling of ED and outpatient visits, respectively. Suicidal and depressed patients presenting to EDs were compared with depressed patients presenting to outpatient clinics. Subgroup analyses included age, sex, race/ethnicity, method of payment, regional variation, and urban verses rural distribution.

Results

Emergency department visits for depression (1.16% of visits in 2002) and suicide attempts (0.51% of visits in 2002) remained stable over the years. Office visits for depression decreased from 3.14% of visits in 2002 to 2.65% of visits in 2008. Non-Latino whites had a higher percentage of ED visits for depression and suicide attempt and office visits for depression than other groups. The percentage of ED visits for suicide attempt resulting in hospital admission decreased by 2.06% per year.

Conclusion

From 2002 to 2008, the percentage of outpatient visits for depression decreased, whereas ED visits for depression and suicide remained stable. When examined in the context of a decreasing prevalence of depression among adults, we conclude that an increasing percentage of the total patients with depression are being evaluated in the ED, vs outpatient clinics.     

National epidemiology of cutaneous abscesses: 1996 to 2005

Objective

Little has been reported regarding the national epidemiology of cutaneous abscesses. We examined the National Hospital Ambulatory Medical Care Survey (NHAMCS) national estimates of all emergency department (ED) visits from 1996 to 2005 to determine the trend and the epidemiology of ED abscess visits.

Methods

Study design: retrospective analysis of NHAMCS databases for 1996 to 2005 available from the National Center for Health Statistics. Subjects: all patients with a first diagnosis of abscess based on the International Classification of Diseases, Ninth Revision, Clinical Modification, diagnosis codes were selected for analysis. Measures: estimated total numbers and percentages of patients by year. Analysis: trends from 1996 through 2005 were examined overall and by demographic factors (eg, age, sex) and abscess characteristics (eg, body region affected). Linear regression was used to evaluate trends.

Results

Emergency department visits for abscesses more than doubled over the 10-year study period (1.2 million in 1996 to 3.28 million in 2005; trend, P < .01). The total number of ED visits increased from 90 million to 115 million over the same period, so that abscess visits are increasing faster than overall visits. Although the frequency of abscesses increased, the demographic and clinical characteristics of ED patients were unchanged over time. About half of ED patients with abscess were male, and about half were between the ages of 19 and 45 years. Annual admissions hovered around 12%. The most common abscess sites coded were the leg, ear, and “unspecified site.” About 50% received antibiotics.

Conclusions

Emergency department visits for abscesses have shown a large increase since 1996; however, demographic and clinical factors are uniform across years.     

Chronic obstructive pulmonary disease surveillance--United States, 1971-2000

PROBLEM/CONDITION: Chronic obstructive pulmonary disease (COPD) includes chronic bronchitis and emphysema but has been defined recently as the physiologic finding of nonreversible pulmonary function impairment. This surveillance summary reports trends in different measures of COPD during 1971-2000. REPORTING PERIOD COVERED: This report presents national data regarding objectively determined COPD (1971-1994); COPD-associated activity and functional limitations (1980-1996); self-reported COPD prevalence, COPD physician office and hospital outpatient department visits, COPD hospitalizations, and COPD deaths (1980-2000); and COPD emergency department visits (1992-2000). DESCRIPTION OF SYSTEMS: The Centers for Disease Control's National Center for Health Statistics conducts the National Health Interview Survey annually, which includes questions concerning COPD and activity limitations. The National Center for Health Statistics collects physician office-visit data in the National Ambulatory Medical Care Survey, emergency department and hospital outpatient department data in the National Hospital Ambulatory Medical Care Survey, hospitalization data in the National Hospital Discharge Survey, and death data in the Mortality Component of the National Vital Statistics System. Data regarding pulmonary function were obtained from the National Health and Nutrition Examination Surveys (NHANES) I (1971-1975) and III (1988-1994), and data regarding functional limitation were obtained from NHANES III, Phase 2 (1991-1994). RESULTS: During 2000, an estimated 10 million U.S. adults reported physician-diagnosed COPD. However, data from NHANES III estimate that approximately 24 million United States adults have evidence of impaired lung function, indicating that COPD is underdiagnosed. During 2000, COPD was responsible for 8 million physician office and hospital outpatient visits, 1.5 million emergency department visits, 726,000 hospitalizations, and 119,000 deaths. During the period analyzed, the most substantial change was the increase in the COPD death rate for women, from 20.1/100,000 in 1980 to 56.7/100,000 in 2000, compared with the more modest increase in the death rate for men, from 73.0/100,000 in 1980 to 82.6/100,000 in 2000. In 2000, for the first time, the number of women dying from COPD surpassed the number of men dying from COPD (59,936 vs 59,118). Another substantial change observed is that the proportion of the population aged < 55 years with mild or moderate COPD, on the basis of pulmonary function testing, decreased from 1971-1975 to 1988-1994, possibly indicating that the upward trends in COPD hospitalizations and mortality might not continue. INTERPRETATION: COPD is a major cause of morbidity, mortality, and disability in the U.S. Despite its ease of diagnosis, COPD remains an underdiagnosed disease, chiefly in its milder and more treatable form.     

The etiology of urinary tract infection: traditional and emerging pathogens

The microbial etiology of urinary infections has been regarded as well established and reasonably consistent. Escherichia coli remains the predominant uropathogen (80%) isolated in acute community-acquired uncomplicated infections, followed by Staphylococcus saprophyticus (10% to 15%). Klebsiella, Enterobacter, and Proteus species, and enterococci infrequently cause uncomplicated cystitis and pyelonephritis.The pathogens traditionally associated with UTI are changing many of their features, particularly because of antimicrobial resistance. The etiology of UTI is also affected by underlying host factors that complicate UTI, such as age, diabetes, spinal cord injury, or catheterization. Consequently, complicated UTI has a more diverse etiology than uncomplicated UTI, and organisms that rarely cause disease in healthy patients can cause significant disease in hosts with anatomic, metabolic, or immunologic underlying disease. The majority of community-acquired symptomatic UTIs in elderly women are caused by E coli. However, gram-positive organisms are common, and polymicrobial infections account for up to 1 in 3 infections in the elderly. In comparison, the most common organisms isolated in children with uncomplicated UTI are Enterobacteriaceae. Etiologic pathogens associated with UTI among patients with diabetes include Klebsiella spp., Group B streptococci, and Enterococcus spp., as well as E coli. Patients with spinal cord injuries commonly have E coli infections. Other common uropathogens include Pseudomonas and Proteus mirabilis.Recent advances in molecular biology may facilitate the identification of new etiologic agents for UTI. The need for accurate and updated population surveillance data is apparent, particularly in light of concerns regarding antimicrobial resistance. This information will directly affect selection of empiric therapy for UTI.     

Uncomplicated UTIs in women

Empirical diagnosis and treatment of lower urinary tract infection (UTI) in women is the most common clinical approach due to the urgency of symptoms and cost. This study examines the importance of recognizing common symptoms and accurately diagnosing UTIs in the primary care setting.     

Treatment cost of acute exacerbations of chronic bronchitis.

In 1994, the National Center for Health Statistics estimated that more than 14 million people (54 per thousand) had chronic bronchitis and sought treatment for 90.9% of their acute episodes. However, few studies have been done on the treatment cost of chronic bronchitis using national data. We conducted a retrospective analysis of claims for patients treated for acute exacerbations of chronic bronchitis (AECB) to assess the frequency of services rendered and the costs to the health care system. Records were selected for the study based on a primary diagnosis of AECB according to the International Classification of Diseases, Ninth Revision, code. Medicare was the primary source of data on patients aged > or =65 years; data from the National Healthcare and Cost Utilization Project, the National Ambulatory Medical Care Survey, and the National Hospital Ambulatory Medical Care Survey were used for patients aged <65 years. We calculated a total treatment cost of $1.2 billion for patients aged > or =65 years and $419 million for patients aged <65 years. These calculations were based on the following: 280,839 hospital discharges resulting in hospital costs of $1.1 billion for the 207,540 patients aged > or =65 years, and $408 million for the 73,299 patients aged <65 years. The mean hospital length of stay was 6.3 days with a mean cost of $5497 for patients aged > or =65 years and 5.8 days with a mean cost of $5561 for younger patients. Room and board represented the largest percentage of the mean hospital costs of AECB. Inpatient physician services cost $32 million and $11 million for the 2 age groups, respectively. Diagnosis-specific data for outpatient services were found to be less reliable than inpatient data, possibly due to diagnostic coding omissions; 331,000 outpatient office visits for AECB were found for those aged > or =65 years and 237,000 visits for those aged <65 years, resulting in respective total outpatient costs of $24.9 million and $15.1 million. If the number of outpatient visits remain consistent with 1994 levels, there would be 5.8 million visits annually for those aged > or =65 years and 4.2 million visits for those aged <65 years; total outpatient costs would be $452 million and $317 million, respectively. Because the treatment costs of AECB are largely the costs of hospitalization, any new therapy that allows more patients to be treated in the outpatient setting is likely to generate significant savings.