Midstream Urine Culture Had a Higher Predictive Value of Post-PNL SIRS in Patients Without Upper Urinary Tract Obstruction

Introduction: Systemic inflammatory response syndrome (SIRS) is a common complication of percutaneous nephrolithotomy (PNL). Midstream urine culture (MUC) is reported to be associated with postoperative SIRS, but this correlation is uncertain, as MUC may not represent infection of obstructed urine in patients with upper urinary tract obstruction (UUTO). Instead, for patients without UUTO, positive MUC may be an indicator of intrarenal infection. The aim of this study was to investigate whether MUC had a higher predictive value in patients without UUTO. Materials and Methods The data of 175 patients who underwent PNL between September 2015 and June 2016 were retrospectively reviewed. Preoperative and intraoperative factors including MUC were collected and analyzed. The primary endpoint was development of SIRS. Subgroup analysis according to the presence of UUTO was conducted. Results Generally, patients who suffered SIRS had a higher incidence of positive MUC (56%[25/45] vs. 32%[41/130], p=0.005). Subgroup analysis showed that among patients without UUTO, positive MUC (75%[13/17] vs. 33%[13/39], p=0.003) was still associated with development of SIRS. Among patients with UUTO, however, there was no obvious correlation between positive MUC and SIRS. Multivariate analysis controlling for age, previous ipsilateral kidney surgery, multiple tracts, and blood creatinine conducted in patients without UUTO demonstrated that positive MUC (odds ratio [OR] = 6.419, 95% confidence interval [CI]: 1.424-28.942, p=0.016) was still associated with development of SIRS. The rate of positive urine culture was 37.7% (66/72), 72 isolates of 24 species were reported, including 6 patients with mixed infection and 2 patients with fungi infection. Gram-negative bacteria accounted for a large proportion of all isolates (68.1%), and Escherichia coli was the most common bacteria (34.7%). Conclusions MUC had a higher predictive value of post-PNL SIRS in patients without UUTO.

Escherichia coli and Klebsiella pneumonia as the Most Common Bacteria Causing Catheter Associated Urinary Tract Infection

Background: Healthcare-Associated Infections (HAIs) are the result of a reaction between taint agents that infected the patient when the patient is hospitalized. A Study from The Center for Disease Control and Prevention shows that most HAIs in hospital are urinary tract infection, most of the infection incident in patient are caused by catheter. Catheter indwelling is notable in medical sphere. This study aimed to inquire case number of Catheter-Associated Urinary Tract Infection (CAUTI) in Dr. Soetomo General Hospital, the feature of CAUTI patients, the type of bacteria that cause CAUTI, and what is the relation among sex and bacteria colony.Materials and Methods: An analytic observational study with the population of pediatric hospitalized patients of Dr. Soetomo General Hospital was conducted in January-December 2017. Samples collected were positive urine culture from pediatric hospitalized patients. Information regarding the bacteria that cause CAUTI, gender, and length of catheter usage were collected.Results: There were total 140 samples of positive urine culture in pediatric patient, and 38.5% was diagnosed as CAUTI. Overall CAUTI was often found in male subjects (51.9 %), and similar with ≤1-year old patients which also often found in male subjects (60.8%). The highest length of catheter usage was 3-5 days (42.5%). All subjects had fever as a clinical sign and 83.3% had suprapubic pain. Escherichia coli and Klebsiella pneumoniae infections were highly discovered. There was an association between gender and urine culture colony count (p=0.02).Conclusion: CAUTI is commonnly found in Dr. Soetomo General Hospital, and two bacteria that cause the most infection were E. coli and K. pneumoniae.Keywords: catheter, urinary tract infection, healthcare associated infection

25 Role of the urinalysis in managing infants less than 60 days old with a positive urine culture

Primary Subject area Hospital Paediatrics Background Urinary tract infections (UTIs) in infants less than 60 days of age, often lead to hospitalization and intravenous antibiotic treatment. There are currently no national recommendations for the diagnosis and management of UTIs in this population. Historically, the urine culture alone was thought to be sufficient for diagnosing UTI due to concerns regarding the sensitivity of urinalysis (UA) in young infants. However, there is evidence that in children of all ages, the absence of pyuria in children with UTIs is rare. The role of the UA in influencing the current management of infants aged less than 60 days, with a positive urine culture, remains unclear. Objectives The objective of this study was to describe the characteristics of infants aged less than 60 days old with a positive urine culture. Specifically, we sought to: 1) determine the differences in clinical and biochemical characteristics of infants with a positive UA versus a negative UA; and 2) determine if UA result was associated with length of intravenous antibiotic treatment. Design/Methods We completed a retrospective cohort study of infants aged 0 to 60 days with a positive urine culture, cared for in a Canadian tertiary care children’s hospital between April 2016 and March 2019. Patients with a history of prematurity and those with a concomitant bacteremia or meningitis were excluded. A positive urine culture was defined as greater than 10,000 CFU/ml of a single organism obtained from a catheter specimen. A positive UA was defined by positive nitrites and/or a positive leukocyte esterase screen, and/or pyuria (greater than 5 white blood cells per high power field). Clinical and biochemical characteristics of infant groups with a positive UA, versus negative UA, were compared. Linear regression analysis was used to understand the association between UA result and length of intravenous antibiotic treatment. Results A total of 718 charts were screened. Eighty-nine patients met inclusion criteria, of which 52 (58%) had a positive UA and 37 (42%) had a negative UA. Of the 89 included infants, the average age was 32.5 days (SD 16.7), 31.5% were female, 79.8% had fever at presentation, and the average length of stay was 5.6 days (SD 2.9). Patients with a positive UA were more often febrile at presentation (90.3% vs. 64.9%, p = 0.006), and had a higher CRP (51.0, SD 56.1 vs. 8.1, SD 13.0), p < 0.001), higher white blood cell count (15.2, SD 6.0 vs. 11.0, SD 5.7, p= 0.002), and more often had urine culture growth of E. Coli (96.2% vs. 62.9%, p < 0.001). UA result was not associated with length of intravenous antibiotic treatment (p= 0.15). Conclusion This study demonstrates that infants with a positive urine culture and a positive UA result had more characteristics of infection, including fever, elevated CRP, elevated white blood cell count, and growth of E. Coli uropathogen, compared to infants with a negative UA. Despite this difference, there was no significant difference in length of intravenous antibiotic treatment between UA-positive versus UA-negative groups. This study suggests that infants with clinical and biochemical findings supportive of a UTI more often had a positive UA, along with a positive culture, and that the UA should be used as a screening test for UTI in infants aged less than 60 days.

Effectiveness of standardized peri-operative protocol with combination of gentamicin and levofloxacin as prophylactic antibiotics on preventing infections after transrectal prostate biopsy: A retrospective study of 577 patients

PurposeThis retrospective study to determine the effectiveness standardized peri-operative protocol in combination with prophylactic gentamicin and levofloxacin in preventing infectious complications after trans-rectal prostate biopsy.Material and MethodPatients were screened for prostate cancer at our out-patient department, either due to abnormal digital examination or elevated PSA level. Patients who underwent transrectal ultrasound (TRUS) guided prostate biopsy from January 2008 to December 2012 was included in this study. After using surgical code to identify the patients, charts were reviewed, and complications were recorded. Infectious complications were defined as any patient who experienced any signs systemic inflammatory response syndrome (SIRS) within 14 days after undergoing TRUS biopsy. Complications were graded according to Clavien-Dindo classification.ResultsOut of the 577 patients there were 20 patients (3.47 %) with infectious complications. Of the 20 patients with infectious complications, only four patients (0.7%) needed hospitalization due to bacteremia. Minor complications (i.e., hematuria, acute urine retention, hematospermia, etc.) were self-resolving. There were 9 positive urine culture and 4 positive blood culture with Escherichia coli (E. coli) as the predominant species. Three patients had positive urine culture for ciprofloxacin resistant strain, which was susceptible to 2nd an 3rd generation cephalosporin or amikacin. One patient had blood culture positive for extended-spectrum beta-lactamase (ESBL) E. coli infection, which was sensitive to amikacin. The infectious complication rate and number decrease each year without increase in resistant strain.ConclusionOur current peri-operative and post-operative protocol appears to be feasible in reducing infection complications after prostate biopsy; our complication and sepsis rate were similar compared to other English literatures. A prospective randomized controlled trial would be needed to determine if a single factor or a combination of several factors are responsible for the reduction in post-biopsy infections.

Impact of Male Patient Information on Quality of Urine Examination (PIQUE Study)

<b><i>Background:</i></b> Urine examination has relevance for treatment, and reliability of positive urine culture (UC) is of importance. The technique of urine sampling (US), storage, and transportation is important. The objective of this study was to investigate if detailed patient information for the technique of US and hygiene reduces rates of contaminated UC in screened male patients, as this group was not investigated yet. <b><i>Methods:</i></b> All patients independently of complaints were enrolled prospectively and consecutively in an outpatient setting in 2 groups – the first group did not receive detailed information and the second group did. We examined 372 consecutive patients in 2017, 190 not receiving (median age 69 years) and 182 receiving information (median age 70 years), with comparable numbers of patients and age. The result of UC and age was imposed. <b><i>Results:</i></b> In all,74.2% of preclarification UC showed a contamination (<i>n</i> = 95) and 75.5% after clarification (<i>n</i> = 83), without significant differences (<i>p</i> = 0.827). This study is limited by the fact that adherence could not be checked. <b><i>Conclusions:</i></b> Similar to studies with females, no difference occurred in rates of contaminated UC, so detailed information regarding the US technique does not decrease rates of contaminated UC and vice versa does not increase the quality of midstream-sampled UC in male patients.

Evaluation of asymptomatic bacteruria management before and after antimicrobial stewardship program implementation: retrospective study

Background The Infectious Diseases Society of America (IDSA) recommends against screening for and/or treating asymptomatic bacteriuria (ASB). This study aims to evaluate the inappropriate use of antibiotics in ASB before and after Antimicrobial Stewardship Program (ASP) implementation and advance towards its appropriate use. Method We performed a retrospective study of patients diagnosed with ASB from 2016 to 2019 at a tertiary hospital in Saudi Arabia. This study included hospitalized patients ≥ 18 years old who had a positive urine culture with no documented signs or symptoms of urinary tract infection We excluded pregnant women, solid organ transplant patients, patient on active chemotherapy, and patients about to undergo urological surgery. Results A total of 716 patients with a positive urine culture were screened. Among these, we identified 109 patients with ASB who were included in our study. The rate of inappropriate antibiotic use was 95% during the study period. The implementation of the ASP Program was associated with a significant reduction in the use of carbapenems (P = 0.04) and an increase in the use of cephalosporins (P = 0.01). However, overprescribing antimicrobial agents was a concern in both eras. Approximately 90% of the microorganisms identified were gram-negative bacteria. Of those, 38.7% were multidrug-resistant strains. Conclusion The urine culture order in ASB is considered relatively small number; however, it showed a high rate of the inappropriate use of antibiotics when there is an order of urine culture in both era. ASP ought to focus on targeting the ordering physician, promoting awareness and/or organizational interventions that appear to reduce the incidence of overtreatment.

Predictive Model for Systemic Infection After Percutaneous Nephrolithotomy and Related Factors Analysis

Objectives: To investigate the factors associated with systemic infection after percutaneous nephrolithotomy (PCNL) and establish a predictive model to provide theoretical basis for the prevention of systemic inflammatory response syndrome (SIRS) and urosepsis correlate to percutaneous nephrostomy.Methods: Patients received PCNL between January 2016 and December 2020 were retrospectively enrolled. All patients were categorized into groups according to postoperative SIRS and urosepsis status. Single factor analysis and multivariate logistic regression analysis were performed to determine the predictive factors of SIRS and urosepsis after PCNL. The nomograms were generated using the predictors respectively and the discriminative ability of was assessed by analyses of receiver operating characteristic curves (ROC curves).Results: A total of 758 PCNL patients were enrolled in this study, including 97 (12.8%) patients with SIRS and 42 (5.5%) patients with urosepsis. Multivariate logistic regression analysis suggested that there were 5 factors related to SIRS, followed by preoperative neutrophil to lymphocyte ratio (NLR) (odds ratio, OR = 1.721, 95% confidence interval, CI [1.116–2.653], p = 0.014), S.T.O.N.E. score (OR = 1.902, 95% CI [1.473–2.457], p &lt; 0.001), female gender (OR = 2.545, 95% CI [1.563–4.144], p &lt; 0.001), diabetes history (OR = 1.987, 95% CI [1.051–3.755], p = 0.035), positive urine culture (OR = 3.184, 95% CI [1.697–5.974], p &lt; 0.001). And there were four factors related to urosepsis, followed by preoperative NLR (OR = 1.604, 95% CI [1.135–2.266], p = 0.007), S.T.O.N.E. score (OR = 1.455, 95% CI [1.064–1.988], p = 0.019), female gender (OR = 2.08, 95% CI [1.063–4.07], p = 0.032), positive urine culture (OR = 2.827, 95% CI [1.266–6.313], p = 0.011). A nomogram prediction model was established to calculate the cumulative probability of SIRS and urosepsis after PCNL and displayed favorable fitting by Hosmer–Lemeshow test (p = 0.953, p = 0.872). The area under the ROC curve was 0.784 (SIRS) and 0.772 (urosepsis) respectively.Conclusion: Higher preoperative NLR, higher S.T.O.N.E. score, female gender, and positive urine culture are the most significant predictors of SIRS and urosepsis. Diabetes history is the predictor of SIRS. These data will help identify high-risk individuals and facilitate early detection of SIRS and urosepsis post-PCNL.

Periprocedural Testing and Antimicrobial Prophylaxis for Ureteral Stent Removal: An Opportunity for Antimicrobial Stewardship

Background: The American Urologic Association’s 2019 Best Practices Statement highlights the importance of procedural and host factors in optimizing antimicrobial prophylaxis for urologic procedures. For ureteral stent removal, a procedure considered low risk, the recommendation for prophylaxis is uncertain and is dependent primarily on patient factors. We examined periprocedural practices and outcomes for both low-risk and intermediate- to high-risk patients undergoing this procedure in a county hospital. Methods: A retrospective cohort study was performed on all patients who underwent stent removal from January to December 2019. Patients were classified as being low risk if they met the following criteria: age 48 hours within the previous 30 days, absence of external urinary catheters, no intermittent catheterization, absence of prosthetic cardiac valves, not pregnant, and not immunocompromised. All other patients were classified as intermediate to high risk. We assessed periprocedural urine testing, antimicrobial prophylaxis, and clinical outcomes. Results: Of 158 unique patients, 84 (53%) were classified as low risk. As shown in Table 1, preprocedural urine cultures were performed in 55% of low-risk versus 69% of intermediate- to high-risk patients. For the patients for whom urine cultures were performed, cultures were positive in 22% of low-risk versus 55% of intermediate- to high-risk patients (p < .0001). All patients received antimicrobial prophylaxis, most often a single dose after the procedure. None of the low risk patients had a positive urine culture or hospitalization within 30 days post procedure. Conclusions: Overall, 53% of patients undergoing stent removal were considered low-risk hosts, yet 100% of patients received antimicrobial prophylaxis. Future studies are needed to evaluate interventions to reduce unnecessary antimicrobial prophylaxis and standardize preprocedural testing in low-risk patients undergoing stent removal.Funding: NoDisclosures: None

Evaluation of Asymptomatic Bacteruria Management Before and After Antimicrobial Stewardship Program Implementation: Retrospective Study

BackgroundThe Infectious Diseases Society of America (IDSA) recommends against screening for and/or treating asymptomatic bacteriuria (ASB). This study aims to evaluate the inappropriate use of antibiotics in ASB before and after Antimicrobial Stewardship Program implementation and advance towards its appropriate use. MethodWe performed a retrospective study of patients diagnosed with ASB from 2016 to 2019 at a tertiary hospital in Saudi Arabia. This study included hospitalized patients ≥18 years old who had a positive urine culture with no signs or symptoms of urinary tract infection and were on antibiotics for asymptomatic bacteriuria. We excluded pregnant women, solid organ transplant patients, patient on active chemotherapy, and patients about to undergo urological surgery.ResultsA total of 716 patients with a positive urine culture were screened . Among these, we identified 109 patients with ASB who were enrolled in our study. The rate of inappropriate antibiotic use was 95% during the study period. The implementation of the Antimicrobial Stewardship Program was associated with a significant reduction in the use of carbapenems (P = 0.04) and an increase in the use of cephalosporins (P = .099687). However, overprescribing antimicrobial agents was a concern in both eras. Approximately 90% of the microorganisms identified were gram-negative bacteria. Of those, 38.7% were multidrug-resistant strains. ConclusionThe urine culture order in ASB is considered relatively small number; however, it showed a high rate of the inappropriate use of antibiotics when there is an order of urine culture in both era. ASP ought to focus on targeting the ordering physician, promoting awareness and/or organizational interventions that appear to reduce the incidence of overtreatment.