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Infectious Disease Clinics of North... Dec 2017Urinary tract infections (UTIs) are a significant cause of morbidity among older adults. However, antibiotic prescriptions for clinically suspected UTIs are often... (Review)
Review
Urinary tract infections (UTIs) are a significant cause of morbidity among older adults. However, antibiotic prescriptions for clinically suspected UTIs are often inappropriate. Health care providers frequently struggle to differentiate UTI from asymptomatic bacteriuria, particularly in patients presenting with nonspecific symptoms. Patients with baseline cognitive impairments that limit history-taking can be particularly challenging. This article reviews the epidemiology and pathogenesis of UTI in older adults. It discusses an approach to diagnosis and treatment focused on recognizing patients who would likely benefit from antibiotic treatment and on identifying patients for whom empiric antibiotic therapy should not be given.
Topics: Aged; Aging; Anti-Bacterial Agents; Bacterial Infections; Bacteriuria; Humans; Urinary Tract Infections
PubMed: 29079155
DOI: 10.1016/j.idc.2017.07.002 -
JAMA Feb 2014Asymptomatic bacteriuria and symptomatic urinary tract infections (UTIs) in older women are commonly encountered in outpatient practice. (Review)
Review
IMPORTANCE
Asymptomatic bacteriuria and symptomatic urinary tract infections (UTIs) in older women are commonly encountered in outpatient practice.
OBJECTIVE
To review management of asymptomatic bacteriuria and symptomatic UTI and review prevention of recurrent UTIs in older community-dwelling women.
EVIDENCE REVIEW
A search of Ovid (Medline, PsycINFO, Embase) for English-language human studies conducted among adults aged 65 years and older and published in peer-reviewed journals from 1946 to November 20, 2013.
RESULTS
The clinical spectrum of UTIs ranges from asymptomatic bacteriuria, to symptomatic and recurrent UTIs, to sepsis associated with UTI requiring hospitalization. Recent evidence helps differentiate asymptomatic bacteriuria from symptomatic UTI. Asymptomatic bacteriuria is transient in older women, often resolves without any treatment, and is not associated with morbidity or mortality. The diagnosis of symptomatic UTI is made when a patient has both clinical features and laboratory evidence of a urinary infection. Absent other causes, patients presenting with any 2 of the following meet the clinical diagnostic criteria for symptomatic UTI: fever, worsened urinary urgency or frequency, acute dysuria, suprapubic tenderness, or costovertebral angle pain or tenderness. A positive urine culture (≥105 CFU/mL) with no more than 2 uropathogens and pyuria confirms the diagnosis of UTI. Risk factors for recurrent symptomatic UTI include diabetes, functional disability, recent sexual intercourse, prior history of urogynecologic surgery, urinary retention, and urinary incontinence. Testing for UTI is easily performed in the clinic using dipstick tests. When there is a low pretest probability of UTI, a negative dipstick result for leukocyte esterase and nitrites excludes infection. Antibiotics are selected by identifying the uropathogen, knowing local resistance rates, and considering adverse effect profiles. Chronic suppressive antibiotics for 6 to 12 months and vaginal estrogen therapy effectively reduce symptomatic UTI episodes and should be considered in patients with recurrent UTIs.
CONCLUSIONS AND RELEVANCE
Establishing a diagnosis of symptomatic UTI in older women requires careful clinical evaluation with possible laboratory assessment using urinalysis and urine culture. Asymptomatic bacteriuria should be differentiated from symptomatic UTI. Asymptomatic bacteriuria in older women should not be treated.
Topics: Aged; Bacteriuria; Female; Humans; Recurrence; Urinary Tract Infections
PubMed: 24570248
DOI: 10.1001/jama.2014.303 -
Journal of Feline Medicine and Surgery Nov 2019Urinary tract infection (UTI) is an important cause of feline lower urinary tract disease (FLUTD), particularly in female cats older than 10 years of age. In addition to... (Review)
Review
PRACTICAL RELEVANCE
Urinary tract infection (UTI) is an important cause of feline lower urinary tract disease (FLUTD), particularly in female cats older than 10 years of age. In addition to cats with typical clinical signs of FLUTD or upper UTI, many cats have subclinical bacteriuria, but the clinical relevance of this is currently uncertain. UTIs are one of the most important indications for antimicrobial use in veterinary medicine and contribute to the development of antimicrobial resistance. Adherence to treatment guidelines and confinement to a few first-line antimicrobial agents is imperative to avoid further deterioration of the antimicrobial resistance situation. The decision to treat with antimicrobials should be based on the presence of clinical signs, and/or concurrent diseases, and the results of urine culture and susceptibility testing.
CLINICAL CHALLENGES
Distinguishing between cats with bacterial cystitis, and those with idiopathic cystitis and concurrent clinical or subclinical bacteriuria, is challenging, as clinical signs and urinalysis results may be identical. Optimal treatment of subclinical bacteriuria requires clarification as there is currently no evidence that demonstrates a beneficial effect of routine treatment. Management of recurrent UTIs remains a challenge as evidence for most alternatives used for prevention in cats is mainly anecdotal, and no preventive treatment modality is currently recommended.
EVIDENCE BASE
This review draws on an extensive literature base in veterinary and human medicine, including the recently updated guidelines of the International Society for Companion Animal Infectious Diseases for the diagnosis and management of bacterial urinary tract infections in dogs and cats. Where published evidence is lacking, the authors describe their own approach; notably, for the bacteriuric cat with chronic kidney disease.
Topics: Animals; Asymptomatic Infections; Bacteriuria; Cat Diseases; Cats; Female; Humans; Male; Urinary Tract Infections
PubMed: 31601143
DOI: 10.1177/1098612X19880435 -
American Family Physician Jul 2020Asymptomatic bacteriuria, defined as the presence of bacteria in the urine in the absence of urinary symptoms, is a common clinical finding that often warrants a...
Asymptomatic bacteriuria, defined as the presence of bacteria in the urine in the absence of urinary symptoms, is a common clinical finding that often warrants a decision about whether to initiate antimicrobial therapy. There are few indications to treat asymptomatic bacteriuria, and inappropriate treatment contributes to the development of antimicrobial resistance. In 2019, the Infectious Diseases Society of America revised its 2005 guidelines on asymptomatic bacteriuria, incorporating new evidence. The updated guidelines recommend screening and appropriate treatment for asymptomatic bacteriuria in pregnant women and in individuals undergoing endourological procedures associated with mucosal trauma. The guidelines recommend against screening and treatment in infants and children; healthy adults, including nonpregnant pre- and postmenopausal women; and patients with diabetes mellitus, long-term indwelling catheters, or spinal cord injuries. The guidelines also recommend against screening and treatment in patients undergoing nonurological surgery, patients who have had a kidney transplant more than one month prior, recipients of other solid organ transplants, or those with impaired voiding following spinal cord injury. Although delirium in older adults can be caused by a urinary tract infection, the guidelines recommend that patients with delirium and no urinary or systemic symptoms be assessed for other causes of delirium, rather than initiating treatment for asymptomatic bacteriuria, because treatment has not been shown to have any beneficial effect on clinical outcomes.
Topics: Adult; Aged; Aged, 80 and over; Anti-Bacterial Agents; Asymptomatic Diseases; Bacteriuria; Curriculum; Education, Medical, Continuing; Female; Health Personnel; Humans; Middle Aged; Pregnancy; Pregnancy Complications; United States; Urinary Tract Infections
PubMed: 32667160
DOI: No ID Found -
Infectious Disease Clinics of North... Mar 2014Urinary tract infection (UTI) is a commonly diagnosed infection in older adults. Despite consensus guidelines developed to assist providers in diagnosing UTI,... (Review)
Review
Urinary tract infection (UTI) is a commonly diagnosed infection in older adults. Despite consensus guidelines developed to assist providers in diagnosing UTI, distinguishing symptomatic UTI from asymptomatic bacteriuria (ASB) in older adults is problematic, as many older adults do not present with localized genitourinary symptoms. This article summarizes the recent literature and guidelines on the diagnosis and management of UTI and ASB in older adults.
Topics: Aged; Algorithms; Anti-Bacterial Agents; Asymptomatic Infections; Bacteriuria; Humans; Middle Aged; Phytotherapy; Practice Guidelines as Topic; Proanthocyanidins; Risk Factors; Urinary Tract Infections; Vaccinium macrocarpon
PubMed: 24484576
DOI: 10.1016/j.idc.2013.10.004 -
The Cochrane Database of Systematic... Nov 2019Asymptomatic bacteriuria is a bacterial infection of the urine without any of the typical symptoms that are associated with a urinary infection, and occurs in 2% to 15%... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Asymptomatic bacteriuria is a bacterial infection of the urine without any of the typical symptoms that are associated with a urinary infection, and occurs in 2% to 15% of pregnancies. If left untreated, up to 30% of mothers will develop acute pyelonephritis. Asymptomatic bacteriuria has been associated with low birthweight and preterm birth. This is an update of a review last published in 2015.
OBJECTIVES
To assess the effect of antibiotic treatment for asymptomatic bacteriuria on the development of pyelonephritis and the risk of low birthweight and preterm birth.
SEARCH METHODS
For this update, we searched the Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (ICTRP) on 4 November 2018, and reference lists of retrieved studies.
SELECTION CRITERIA
Randomised controlled trials (RCT) comparing antibiotic treatment with placebo or no treatment in pregnant women with asymptomatic bacteriuria found on antenatal screening. Trials using a cluster-RCT design and quasi-RCTs were eligible for inclusion, as were trials published in abstract or letter form, but cross-over studies were not.
DATA COLLECTION AND ANALYSIS
Two review authors independently assessed trials for inclusion and risk of bias, extracted data, and checked for accuracy. We assessed the quality of the evidence using the GRADE approach.
MAIN RESULTS
We included 15 studies, involving over 2000 women. Antibiotic treatment compared with placebo or no treatment may reduce the incidence of pyelonephritis (average risk ratio (RR) 0.24, 95% confidence interval (CI) 0.13 to 0.41; 12 studies, 2017 women; low-certainty evidence). Antibiotic treatment may be associated with a reduction in the incidence of preterm birth (RR 0.34, 95% CI 0.13 to 0.88; 3 studies, 327 women; low-certainty evidence), and low birthweight babies (average RR 0.64, 95% CI 0.45 to 0.93; 6 studies, 1437 babies; low-certainty evidence). There may be a reduction in persistent bacteriuria at the time of delivery (average RR 0.30, 95% CI 0.18 to 0.53; 4 studies; 596 women), but the results were inconclusive for serious adverse neonatal outcomes (average RR 0.64, 95% CI 0.23 to 1.79, 3 studies; 549 babies). There were very limited data on which to estimate the effect of antibiotics on other infant outcomes, and maternal adverse effects were rarely described. Overall, we judged only one trial at low risk of bias across all domains; the other 14 studies were assessed as high or unclear risk of bias. Many studies lacked an adequate description of methods, and we could only judge the risk of bias as unclear, but in most studies, we assessed at least one domain at high risk of bias. We assessed the quality of the evidence for the three primary outcomes with GRADE software, and found low-certainty evidence for pyelonephritis, preterm birth, and birthweight less than 2500 g.
AUTHORS' CONCLUSIONS
Antibiotic treatment may be effective in reducing the risk of pyelonephritis in pregnancy, but our confidence in the effect estimate is limited given the low certainty of the evidence. There may be a reduction in preterm birth and low birthweight with antibiotic treatment, consistent with theories about the role of infection in adverse pregnancy outcomes, but again, the confidence in the effect is limited given the low certainty of the evidence. Research implications identified in this review include the need for an up-to-date cost-effectiveness evaluation of diagnostic algorithms, and more evidence to learn whether there is a low-risk group of women who are unlikely to benefit from treatment of asymptomatic bacteriuria.
Topics: Anti-Bacterial Agents; Asymptomatic Infections; Bacteriuria; Female; Humans; Infant, Low Birth Weight; Infant, Newborn; Pregnancy; Pregnancy Complications, Infectious; Pregnancy Outcome; Premature Birth; Pyelonephritis; Randomized Controlled Trials as Topic
PubMed: 31765489
DOI: 10.1002/14651858.CD000490.pub4 -
Deutsches Arzteblatt International May 2010Urinary tract infections (UTI) are among the leading reasons for treatment in adult primary care medicine, accounting for a considerable percentage of antibiotic... (Review)
Review
BACKGROUND
Urinary tract infections (UTI) are among the leading reasons for treatment in adult primary care medicine, accounting for a considerable percentage of antibiotic prescriptions. Because this problem is so common and so significant in routine clinical practice, a high level of diagnostic accuracy is essential. Antibiotics should not be prescribed excessively, particularly in view of the increasing prevalence of antibiotic resistance.
METHOD
Systematic review of relevant articles that were retrieved by a search of the Medline, Embase, and Cochrane Library databases. The recommendations of selected international guidelines were also taken into account, as were the German national quality standards for microbiological diagnosis.
RESULTS
The diagnosis of UTI by clinical criteria alone has an error rate of approximately 33%. The use of refined diagnostic algorithms does not completely eliminate uncertainty.
CONCLUSION
With the aid of a small number of additional diagnostic criteria, antibiotic treatment for UTI can be provided more specifically and thus more effectively. Differentiating UTI from asymptomatic bacteriuria, which usually requires no treatment, can lower the frequency of unnecessary antibiotic prescriptions.
Topics: Adolescent; Adult; Aged; Algorithms; Anti-Bacterial Agents; Bacterial Infections; Bacteriuria; Child; Colony-Forming Units Assay; Cystitis; Drug Resistance, Multiple, Bacterial; Female; Humans; Male; Microbial Sensitivity Tests; Middle Aged; Practice Guidelines as Topic; Pregnancy; Primary Health Care; Quality Assurance, Health Care; Risk Factors; Urinary Tract Infections; Young Adult
PubMed: 20539810
DOI: 10.3238/arztebl.2010.0361 -
Microbiology Spectrum Apr 2016Gram-positive bacteria are a common cause of urinary-tract infection (UTI), particularly among individuals who are elderly, pregnant, or who have other risk factors for... (Review)
Review
Gram-positive bacteria are a common cause of urinary-tract infection (UTI), particularly among individuals who are elderly, pregnant, or who have other risk factors for UTI. Here we review the epidemiology, virulence mechanisms, and host response to the most frequently isolated Gram-positive uropathogens: Staphylococcus saprophyticus, Enterococcus faecalis, and Streptococcus agalactiae. We also review several emerging, rare, misclassified, and otherwise underreported Gram-positive pathogens of the urinary tract including Aerococcus, Corynebacterium, Actinobaculum, and Gardnerella. The literature strongly suggests that urologic diseases involving Gram-positive bacteria may be easily overlooked due to limited culture-based assays typically utilized for urine in hospital microbiology laboratories. Some UTIs are polymicrobial in nature, often involving one or more Gram-positive bacteria. We herein review the risk factors and recent evidence for mechanisms of bacterial synergy in experimental models of polymicrobial UTI. Recent experimental data has demonstrated that, despite being cleared quickly from the bladder, some Gram-positive bacteria can impact pathogenic outcomes of co-infecting organisms. When taken together, the available evidence argues that Gram-positive bacteria are important uropathogens in their own right, but that some can be easily overlooked because they are missed by routine diagnostic methods. Finally, a growing body of evidence demonstrates that a surprising variety of fastidious Gram-positive bacteria may either reside in or be regularly exposed to the urinary tract and further suggests that their presence is widespread among women, as well as men. Experimental studies in this area are needed; however, there is a growing appreciation that the composition of bacteria found in the bladder could be a potentially important determinant in urologic disease, including susceptibility to UTI.
Topics: Animals; Bacteriuria; Gram-Positive Bacteria; Gram-Positive Bacterial Infections; Humans; Microbiota; Urinary Tract; Urinary Tract Infections
PubMed: 27227294
DOI: 10.1128/microbiolspec.UTI-0012-2012 -
BMC Geriatrics Feb 2019Non-specific symptoms, such as confusion, are often suspected to be caused by urinary tract infection (UTI) and continues to be the most common reason for suspecting a...
BACKGROUND
Non-specific symptoms, such as confusion, are often suspected to be caused by urinary tract infection (UTI) and continues to be the most common reason for suspecting a UTI despite many other potential causes. This leads to significant overdiagnosis of UTI, inappropriate antibiotic use and potential harmful outcomes. This problem is particularly prevalent in nursing home settings.
METHODS
A systematic review of the literature was conducted assessing the association between confusion and UTI in the elderly. PubMed, Scopus and PsychInfo were searched with the following terms: confusion, delirium, altered mental status, acute confusional state, urinary tract infection, urine infection, urinary infection and bacteriuria. Inclusion criteria and methods were specified in advance and documented in the protocol, which was published with PROSPERO (registration ID: CRD42015025804). Quality assessment was conducted independently by two authors. Data were extracted using a standardised extraction tool and a qualitative synthesis of evidence was made.
RESULTS
One thousand seven hunderd two original records were identified, of which 22 were included in the final analysis. The quality of these included studies varied, with frequent poor case definitions for UTI or confusion contributing to large variation in results and limiting their validity. Eight studies defined confusion using valid criteria; however, no studies defined UTI in accordance with established criteria. As no study used an acceptable definition of confusion and UTI, an association could not be reliably established. Only one study had acceptable definitions of confusion and bacteriuria, reporting an association with the relative risk being 1.4 (95% CI 1.0-1.7, p = 0.034).
CONCLUSIONS
Current evidence appears insufficient to accurately determine if UTI and confusion are associated, with estimates varying widely. This was often attributable to poor case definitions for UTI or confusion, or inadequate control of confounding factors. Future well-designed studies, using validated criteria for UTI and confusion are required to examine the relationship between UTI and acute confusion in the elderly. The optimal solution to clarify this clinical issue would be a randomized controlled trial comparing the effect of antibiotics versus placebo in patients with new onset or worsening confusion and presence of bacteriuria while lacking specific urinary tract symptoms.
Topics: Aged; Aged, 80 and over; Anti-Bacterial Agents; Bacteriuria; Delirium; Evidence-Based Medicine; Female; Humans; Male; Nursing Homes; Risk; Urinary Tract Infections
PubMed: 30717706
DOI: 10.1186/s12877-019-1049-7 -
Microbiology Spectrum Oct 2015Asymptomatic bacteriuria is very common. In healthy women, asymptomatic bacteriuria increases with age, from <1% in newborns to 10% to 20% of women age 80 years, but is... (Review)
Review
Asymptomatic bacteriuria is very common. In healthy women, asymptomatic bacteriuria increases with age, from <1% in newborns to 10% to 20% of women age 80 years, but is uncommon in men until after age 50 years. Individuals with underlying genitourinary abnormalities, including indwelling devices, may also have a high frequency of asymptomatic bacteriuria, irrespective of age or gender. The prevalence is very high in residents of long-term-care facilities, from 25% to 50% of women and 15% to 40% of men. Escherichia coli is the most frequent organism isolated, but a wide variety of other organisms may occur. Bacteriuria may be transient or persist for a prolonged period. Pregnant women with asymptomatic bacteriuria identified in early pregnancy and who are untreated have a risk of pyelonephritis later in pregnancy of 20% to 30%. Bacteremia is frequent in bacteriuric subjects following mucosal trauma with bleeding, with 5% to 10% of patients developing severe sepsis or septic shock. These two groups with clear evidence of negative outcomes should be screened for bacteriuria and appropriately treated. Asymptomatic bacteriuria in other populations is benign and screening and treatment are not indicated. Antimicrobial treatment has no benefits but is associated with negative outcomes including reinfection with antimicrobial resistant organisms and a short-term increased frequency of symptomatic infection post-treatment. The observation of increased symptomatic infection post-treatment, however, has led to active investigation of bacterial interference as a strategy to prevent symptomatic episodes in selected high risk patients.
Topics: Adolescent; Adult; Aged; Aged, 80 and over; Antibiosis; Asymptomatic Diseases; Bacteremia; Bacteriuria; Biological Therapy; Child; Child, Preschool; Escherichia coli; Female; Humans; Infant; Infant, Newborn; Male; Middle Aged; Pregnancy; Pregnancy Complications, Infectious; Prevalence; Pyelonephritis; Young Adult
PubMed: 26542046
DOI: 10.1128/microbiolspec.UTI-0001-2012