Infect Control Hosp Epidemiol

Objective:To evaluate the impact of changes to urine testing orderables in computerized physician order entry (CPOE) system on urine culturing practices.Design:Retrospective before (January 2015 to April 2016) and after (May 2016 to August 2017) study.Setting:A 1,250-bed academic tertiary referral center.Patients:Hospitalized adults who had 651 urine culture performed during their stay.Intervention:The intervention (implemented in April 2017) consisted of notifications to providers, changes to order sets and inclusion of the new urine culture reflex tests in commonly used order sets. We compared the urine culture rates before and after intervention, adjusting for temporal trends.Results:During the study period, 18,954 inpatients (median age 62 years, 68.8% white and 52.3% female) had 24,569 urine cultures ordered. Twenty-seven percent (n=6642) of the urine cultures were positive. Urine culturing rate decreased significantly in the post-intervention period for any specimen type (38.1 pre-vs. 20.9 per 1000 patient days post-intervention, p<0.001), clean catch (30.0 vs. 18.7, p<0.001) and catheterized urine (7.8 vs. 1.9, p<0.001). Using an interrupted time series model, urine culture rates decreased for all specimen types (p<0.05).Conclusions:Our intervention of changes to order sets and inclusion of the new urine culture reflex tests resulted in a 45% reduction in the urine cultures ordered. CPOE system format plays a vital role in reducing the burden of unnecessary urine cultures and should be implemented in combination with other efforts.U54 CK000482/CK/NCEZID CDC HHS/United States2019-09-01T00:00:00Z30786940PMC6433134661

Evidence-driven Diagnosis and Treatment of Acute Urinary Tract Infections in Long-term Care

Misdiagnosis of asymptomatic bacteriuria as a urinary tract infection continues to occur, leading to the overuse of antibiotics. Due to the growing elderly population in long-term care facilities (LTCFs), LTCFs can play a critical role in antimicrobial stewardship. Urinary tract infections are a starting point for moving toward antimicrobial stewardship, since urinary tract infections are common in LTCFs. A retrospective chart review of 156 cases with suspected urinary tract infections (UTIs) was completed in a LTCF. The purpose of the scholarly project was to assess diagnostic and treatment practices for UTIs and compare them to a diagnostic and treatment algorithm. The overarching finding of the scholarly project was that this particular LTCF’s management of UTIs did not correspond with the selected algorithm’s recommendations. Because the elderly frequently have complex and confounding health factors related to UTIs, the selected algorithm did not adequately capture the nuances for UTI diagnosis in the elderly population. As currently published, the algorithm is not generalizable to elderly women in LTCFs. The symptoms component of the diagnostic portion of the algorithm may benefit from further revision for use in the elderly population. Small-scale change at LTCFs could include encouragement of watchful waiting and improved use of guidelines for antibiotic treatment

An Algorithm (LaD) for Monitoring Childbirth in Settings Where Tracking All Parameters in the World Health Organization Partograph Is Not Feasible: Design and Expert Validation

Background: After determining the key childbirth monitoring items from experts, we designed an algorithm (LaD) to represent the experts’ suggestions and validated it. In this paper we describe an abridged algorithm for labor and delivery management and use theoretical case to compare its performance with human childbirth experts. Objective: The objective of this study was to describe the LaD algorithm, its development, and its validation. In addition, in the validation phase we wanted to assess if the algorithm was inferior, equivalent, or superior to human experts in recommending the necessary clinical actions during childbirth decision making. Methods: The LaD algorithm encompasses the tracking of 6 of the 12 childbirth parameters monitored using the World Health Organization (WHO) partograph. It has recommendations on how to manage a patient when parameters are outside the normal ranges. We validated the algorithm with purposively selected experts selecting actions for a stratified sample of patient case scenarios. The experts’ selections were compared to obtain pairwise sensitivity and false-positive rates (FPRs) between them and the algorithm. Results: The mean weighted pairwise sensitivity among experts was 68.2% (SD 6.95; 95% CI 59.6-76.8), whereas that between experts and the LaD algorithm was 69.4% (SD 17.95; 95% CI 47.1-91.7). The pairwise FPR among the experts ranged from 12% to 33% with a mean of 23.9% (SD 9.14; 95% CI 12.6-35.2), whereas that between experts and the algorithm ranged from 18% to 43% (mean 26.3%; SD 10.4; 95% CI 13.3-39.3). The was a correlation (mean 0.67 [SD 0.06]) in the actions selected by the expert pairs for the different patient cases with a reliability coefficient (α) of .91. Conclusions: The LaD algorithm was more sensitive, but had a higher FPR than the childbirth experts, although the differences were not statistically significant. An electronic tool for childbirth monitoring with fewer WHO-recommended parameters may not be inferior to human experts in labor and delivery clinical decision support.publishedVersio

Abordagem da antibioterapia no tratamento da bacteriúria assintomática

Dissertação para obtenção do grau de Mestre no Instituto Universitário Egas MonizA ASB (ASB) é a presença de uma ou mais espécies de bactérias que crescem na urina em contagens iguais ou superiores a 105 unidades formadoras de colónias (UFC)/mL ou iguais ou superiores a 108 UFC/L. De acordo com a pesquisa realizada, os resultados obtidos nos estudos utilizados nesta monografia, sugerem que a ASB é detetada com mais frequência em mulheres com idade inferior a 60 anos, doentes com diabetes e idosos. Independentemente da presença de piúria, na ausência de sinais ou sintomas atribuíveis à ITU (ITU), a ASB é comum em algumas populações femininas saudáveis e em muitas mulheres ou homens, com anormalidades do aparelho geniturinário que prejudicam a micção. A pergunta a que se pretende obter resposta é se a utilização de antibióticos no tratamento da ASB em adultos é benéfica, sendo que o benefício no seu tratamento é um assunto ainda bastante controverso. A prevalência da ASB sabe-se que varia de acordo com a idade, sexo, atividade sexual e a presença de anormalidades geniturinárias. Encontra-se também aumentada em doentes diabéticos e em idosos. Em homens jovens a ASB é rara, aumentando a sua prevalência a partir dos 60 anos; é comum, e o seu rastreio em mulheres grávidas constitui uma prática corrente baseada na evidência. Estudos epidemiológicos e clínicos têm demonstrado que na maioria das situações clínicas, a ASB é inofensiva, não tendo qualquer correlação com doenças infeciosas graves, complicações e portanto, não requer tratamento. No entanto, muitos pacientes com ASB são tratados desnecessariamente, resultando em morbidades associadas aos antibióticos e uma seleção de resistência antimicrobiana. É por isso muito importante identificar as situações clínicas especiais para as quais a eliminação da doença é benéfica e o tratamento é recomendado.Asymptomatic bacteriuria (ASB) is the presence of one or more species of bacteria that grow in the urine in counts of equal to or greater than 105 colony forming units (CFU)/mL or equal to or greater than 108 CFU/L. According to the search that was made, the results obtained in the studies utilized in this monography suggest that asymptomatic bacteriuria is most often detected in women with age below 60 years old, people with diabetes and older people. Regardless of the presence of pyuria, in the absence of signs or symptoms attributable to the infection of the urinary tract, ASB is common in some healthy female populations as well as in women and men with abnormalities in their genitourinary tract which prejudice the urination. The question whose answer is pretended to be found is if the use of antibiotics during the treatment of asymptomatic bacteriuria is indeed beneficial, being considered that its use during the treatment is controversial. It is known that the prevalence of asymptomatic bacteriuria varies due to age, gender, sexual activity and the presence of abnormalities in the genitourinary tract. It is also increased in people with diabetes and in elderly populations. Amongst young men, asymptomatic bacteriuria is rare, being that its prevalence increases as from 60 years old; the tracking in pregnant women is considered a common practice based on the evidence. Epidemiologic and clinical studies have demonstrated thus far that in most situations, asymptomatic bacteriuria is harmless and doesn’t have any correlation with serious infectious diseases, thus not requiring any treatment. However, many of the patients with asymptomatic bacteriuria are treated unnecessarily which results in antibiotic associated morbidity and antimicrobial resistance. Because of that, is of the utmost importance to identify the clinical situations for which the disease elimination is beneficial and the treatment is recommended

Smoking and Second Hand Smoking in Adolescents with Chronic Kidney Disease: A Report from the Chronic Kidney Disease in Children (CKiD) Cohort Study

The goal of this study was to determine the prevalence of smoking and second hand smoking [SHS] in adolescents with CKD and their relationship to baseline parameters at enrollment in the CKiD, observational cohort study of 600 children (aged 1-16 yrs) with Schwartz estimated GFR of 30-90 ml/min/1.73m2. 239 adolescents had self-report survey data on smoking and SHS exposure: 21 [9%] subjects had “ever” smoked a cigarette. Among them, 4 were current and 17 were former smokers. Hypertension was more prevalent in those that had “ever” smoked a cigarette (42%) compared to non-smokers (9%), p\u3c0.01. Among 218 non-smokers, 130 (59%) were male, 142 (65%) were Caucasian; 60 (28%) reported SHS exposure compared to 158 (72%) with no exposure. Non-smoker adolescents with SHS exposure were compared to those without SHS exposure. There was no racial, age, or gender differences between both groups. Baseline creatinine, diastolic hypertension, C reactive protein, lipid profile, GFR and hemoglobin were not statistically different. Significantly higher protein to creatinine ratio (0.90 vs. 0.53, p\u3c0.01) was observed in those exposed to SHS compared to those not exposed. Exposed adolescents were heavier than non-exposed adolescents (85th percentile vs. 55th percentile for BMI, p\u3c 0.01). Uncontrolled casual systolic hypertension was twice as prevalent among those exposed to SHS (16%) compared to those not exposed to SHS (7%), though the difference was not statistically significant (p= 0.07). Adjusted multivariate regression analysis [OR (95% CI)] showed that increased protein to creatinine ratio [1.34 (1.03, 1.75)] and higher BMI [1.14 (1.02, 1.29)] were independently associated with exposure to SHS among non-smoker adolescents. These results reveal that among adolescents with CKD, cigarette use is low and SHS is highly prevalent. The association of smoking with hypertension and SHS with increased proteinuria suggests a possible role of these factors in CKD progression and cardiovascular outcomes