Longer than recommended empiric antibiotic treatment of urinary tract infection in women: an avoidable waste of money

CONTEXT: Current Israeli guidelines for the empiric treatment of uncomplicated urinary tract infection (UTI) in women recommend nitrofurantoin for 5 days. Some physicians nevertheless opt for ofloxacin, which should be prescribed for 3 days according to universally accepted guidelines. OBJECTIVE: To evaluate the economic consequences of longer than recommended durations of antibiotic therapy in the empiric treatment of uncomplicated UTI in women. DESIGN, SETTING AND PATIENTS: Data were derived from the electronic records of one of the four health maintenance organizations in Israel. The sample included all women aged 18-75 years who were diagnosed with acute cystitis or UTI from January 2001 to June 2002 and were empirically treated with antibiotics. Of the 7738 patients identified, 1138 received nitrofurantoin and 1054 ofloxacin. The excess expenditure accrued due to longer than recommended therapy with these drugs was evaluated. RESULTS: The rate of adherence was 22.23% for nitrofurantoin (95% CI=19.81%, 24.65%), and 4.08% for ofloxacin (95% CI=2.88%, 5.28%). The average excess expenditure per case was 5.78 USD (US Dollar) with ofloxacin and 3.43 USD with nitrofurantoin, resulting in an annual loss to the health maintenance organizations of approximately 19,000 USD. When extrapolated to the national population of 6.5 million, the loss due to inappropriate treatment of adult women is 190,000 USD. CONCLUSIONS: The lack of adherence to national and international guidelines with regard to the recommended duration of antibiotic treatment of UTI in women resulted in a significant and avoidable waste of health system resources. This study suggests that drug utilization analyses that concentrate solely on the choice of drug may be overlooking important information.     

Flora distribution and drug resistance in catheter‐associated urinary tract infection

To investigate flora distribution and drug resistance in catheter‐associated urinary tract infection. From January 2003 to January 2008 1,567 patients with urinary tract infection associated with the use of indwelling urinary catheters were analyzed retrospectively, whose urine specimens were cultured for bacteria and the isolated pathogens were tested for drug sensitivity by Kirby‐Baue method. 376 pathogens were isolated from the 1,567 urine specimens (24·0%), most of which were Gram‐negative bacteria. The extended spectrum β‐lactamase (ESBL) rate was 59·8% (79/132) for Escherichia coli and 47·4% (18/38) for Klebsiella pnuemoniae. The isolating rate of Methcillin‐resistant Staphylococcus aureus and Methcillin‐resistant Staphylococcus epidermidis was 54·7% and 88·2% respectively. Catheter‐associated urinary tract infection is mainly caused by Gram‐negative bacteria of multi‐drug resistance. Use of antibiotics should be based on drug sensitivity tests.     

1042例尿路感染致病菌分布及耐药性分析

目的 研究泌尿系统感染常见致病菌的分布及耐药情况,指导临床合理使用抗菌药物。方法 回顾性分析2013~2015年该院泌尿外科住院病历,对泌尿感染患者的细菌培养及药敏结果进行统计分析。结果 共检出1 042株致病菌,革兰阴性菌占总细菌数的79.0%,革兰阳性菌占15.3%,真菌占5.7%。其中革兰阴性菌以大肠埃希菌为主,革兰阳性菌以肠球菌属为主。革兰阴性菌对于头孢曲松、头孢噻肟、左氧氟沙星、复方磺胺甲噁唑、环丙沙星、氨曲南、头孢吡肟耐药率均比较高,对于哌拉西林-他唑巴坦、亚胺培南的耐药率低于6.0%;革兰阳性菌对万古霉素、利奈唑胺、呋喃妥因均较敏感,对克林霉素、红霉素、头孢曲松的耐药率较高(70.0%)。结论 临床在选择抗菌药物时应充分结合细菌培养及药敏结果,合理使用抗菌药物。     

Evaluation of a service development to increase detection of urinary tract infections in children

RATIONALE, AIMS AND OBJECTIVES: It is suspected that childhood urinary tract infection (UTI) remains under-diagnosed in primary care, and is consequently the cause of subsequent morbidity from renal scarring, hypertension and eventual renal failure. Practice-based education and service developments were undertaken to try to improve the detection of childhood UTI. METHODS: A controlled before-and-after intervention study was conducted. The educational and service developments promoted awareness of and greater testing for UTI among children less than two years of age presenting with febrile illness or other potentially relevant symptoms or signs. Appropriate diagnostic equipment was provided. RESULTS AND CONCLUSIONS: More urine samples were sent by the intervention practices but without a concomitant increase in detection of UTIs. This may indicate that current practice is approaching near maximal detection of UTI in young children.     

Challenges to nurse prescribers of a no‐antibiotic prescribing strategy for managing self‐limiting respiratory tract infections

Aims. To report a qualitative study of the experiences of nurse prescribers in managing patients with self‐limiting respiratory tract infections. Background. Patients frequently attend primary care with respiratory tract infections. Although a no‐prescribing strategy is recommended for these consultations, general practitioners frequently prescribe antibiotics, citing non‐clinical reasons such as patient pressure. Nurses increasingly manage people with respiratory tract infections, but research has not yet explored their experiences within such consultations. Design. Semi‐structured interviews and focus groups. Methods. Fifteen semi‐structured interviews and three focus groups (n = 5, n = 4, and n = 12) with a purposive sample of nurse prescribers (n = 34) and other non‐medical prescribers (n = 2) were conducted between November 2009–November 2010. A qualitative approach was used to develop conceptual categories from the dataset, and emerging themes were explored in subsequent interviews/focus groups. Findings. Although participants reported experiencing numerous challenges within these consultations, they believed that they possessed some of the communication skills to deal effectively with patients without prescribing antibiotics. Participants reported that protocols supported their decision‐making and welcomed the benefits of peer support in dealing with ‘demanding’ patients. However, the newness of nurses and other non‐medical prescribers to the prescribing role meant that some were cautious in dealing with patients with respiratory tract infections. Conclusion. Training for nurses and other non‐medical prescribers should focus on building their confidence and skills to manage people with respiratory tract infections without recourse to antibiotics. Further work should seek to explore which strategies are most effective in managing respiratory tract infections while maintaining patient satisfaction with care.     

Prevalence of urinary tract infection (UTI) in sequential acutely unwell children presenting in primary care: Exploratory study

Abstract

Background. Due to the non-specific nature of symptoms of UTI in children and low levels of urine sampling, the prevalence of UTI amongst acutely ill children in primary care is unknown. Objectives. To undertake an exploratory study of acutely ill children consulting in primary care, determine the feasibility of obtaining urine samples, and describe presenting symptoms and signs, and the proportion with UTI. Design. Exploratory, observational study. Setting. Four general practices in South Wales. Subjects. A total of 99 sequential attendees with acute illness aged less than five years. Main outcome measure. UTI defined by >10⁵ organisms/ml on laboratory culture of urine. Results. Urine samples were obtained in 75 (76%) children. Three (4%) met microbiological criteria for UTI. GPs indicated they would not normally have obtained urine samples in any of these three children. However, all had received antibiotics for suspected alternative infections. Conclusion. Urine sample collection is feasible from the majority of acutely ill children in primary care, including infants. Some cases of UTI may be missed if children thought to have an alternative site of infection are excluded from urine sampling. A larger study is needed to more accurately determine the prevalence of UTI in children consulting with acute illness in primary care, and to explore which symptoms and signs might help clinicians effectively target urine sampling.     

Is a negative dipstick urinalysis good enough to exclude urinary tract infection in paediatric emergency department patients?

Background: Urinary tract infection is a common cause of serious bacterial infection in young children. The non‐specific presentation has implications for misdiagnosis and the potential for long‐term complications. Aims: To determine if a negative dipstick urinalysis is adequate to exclude urinary tract infection in children aged 0–10 years. Data was subdivided into two age groups: 0–2 years and 2–10 years. Methods: Retrospective case note review over an 8‐month period. Cases included required a printed urinalysis recorded from the Clinitek 50 (Bayer) machine and a printed microscopy and culture result. We defined a negative urinalysis as being negative for all of blood, protein, leucocytes and nitrites. A total of 375 cases were included for statistical calculation. Results: Three hundred and seventy‐five cases gave a prevalence of 10.7% with a sensitivity of 92.5%, specificity of 39.4% and a negative predictive value of 97.8%. In the 0–2‐year‐old group, we demonstrated a prevalence of 15%, a sensitivity of 87.5%, specificity of 39.7% and a negative predictive value of 94.7%. This compares to the older group (2–10 years) with a prevalence of 7.0%, a sensitivity of 100%, specificity of 39.7% and a negative predictive value of 100%. Conclusions: Prevalence of urinary tract infection varied with age with a higher prevalence in the 0–2 years age group. The lower negative predictive value and the higher clinical importance in this age group means that dipstick urinalysis is inadequate to exclude urinary tract infection. Conversely, we believe that children in the 2–10 years age group can adequately have urinary tract infection excluded with a negative dipstick urinalysis.     

Methenamine: a forgotten drug for preventing recurrent urinary tract infection in a multidrug resistance era

In the era of multidrug resistance, it is critical to utilize antibiotics in an appropriate manner and to identify new treatments or revisit the use of ‘forgotten’ drugs. Because urinary tract infections (UTIs) are common, particularly in an increasing elderly population, the ‘forgotten’ drug, methenamine, may become important as a preventive therapy for recurrent UTIs. Methenamine, a urinary antibacterial agent, can be used as methenamine hippurate or methenamine mandelate preparations and is United States Food and Drug Administration-approved. This article discusses the place of preventive therapy for recurrent UTIs, chemistry, mechanism of action, pharmacology, clinical uses, dosage, adverse reactions and safety, and drug interactions of methenamine. Because of its unique antiseptic property, the authors suggest that methenamine should be considered when more commonly used antibiotics fail to suppress recurrent UTIs.     

Efficacy of contrast-enhanced percutaneous nephrosonography to evaluate urinary tract patency in children

A novel method known as contrast-enhanced percutaneous nephrosonography (cePNS), using an ultrasound contrast agent administered through the nephrostomy catheter, has been used to evaluate the urinary tract patency in children. Nine cePNS examinations were performed in seven children to evaluate the urinary tract patency prior to further management. The cePNS results were compared with the clinical evaluation of patent urinary tract cases or with surgery results. Both, the technical success rate and accuracy of cePNS examinations were 100%. CePNS is a radiation-free method and can be performed as a continuation of an ultrasound examination.     

A nurse–family partnership intervention to increase the self‐efficacy of family caregivers and reduce catheter‐associated urinary tract infection in catheterized patients

The purpose of this study was to evaluate the effects of a nurse–family partnership model on the self‐efficacy of family caregivers (FCs) and the incidence of catheter‐associated urinary tract infection (CAUTI) among patients. A randomized controlled study was conducted. We recruited 61 patients and their FCs, who were randomly divided into an experimental group (n = 30) and a control group (n = 31). In the experimental group, the main caregivers comprised a nurse–family partnership, whereas the control participants received routine care. The findings were as follows: (i) the incidence of CAUTI was lower in the experimental group than in the control group (20% vs. 38.8%), but the difference was not statistically significant; and (ii) no significant difference emerged for reported Caregiver Self‐Efficacy Score between the two groups. The nursing team and FCs must become partners in cooperative caregiving to enhance the quality of patient care.