#Screening for Asymptomatic #Bacteriuria in #Adults – Updated #Evidence #Report and Systematic #Review for the #US Preventive Services Task Force (JAMA, abstract)

[Source: Journal of the American Medical Association, full page: (LINK). Abstract, edited.]

US Preventive Services Task Force  / Evidence Report / September 24, 2019

Screening for Asymptomatic Bacteriuria in Adults – Updated Evidence Report and Systematic Review for the US Preventive Services Task Force

Jillian T. Henderson, PhD, MPH1; Elizabeth M. Webber, MS1; Sarah I. Bean, MPH1

Author Affiliations: 1 Center for Health Research, Kaiser Permanente Research Affiliates Evidence-based Practice Center, Kaiser Permanente, Portland, Oregon

JAMA. 2019;322(12):1195-1205. doi:10.1001/jama.2019.10060

 

Abstract

Importance  

Screening for asymptomatic bacteriuria can identify patients for whom treatment might be beneficial for preventing symptomatic infection and other health outcomes.

Objective  

To systematically review benefits and harms of asymptomatic bacteriuria screening and treatment in adults, including during pregnancy, to inform the US Preventive Services Task Force.

Data Sources  

MEDLINE, PubMed (publisher-supplied records), and Cochrane Collaboration Central Registry of Controlled Trials; surveillance through May 24, 2019.

Study Selection  

Randomized clinical trials (RCTs) and observational studies on benefits and harms of screening for asymptomatic bacteriuria; RCTs on benefits and harms of asymptomatic bacteriuria treatment. Eligible populations included unselected, asymptomatic individuals without known urinary tract conditions.

Data Extraction and Synthesis  

Independent critical appraisal and data abstraction by 2 reviewers. Random-effects meta-analysis was conducted to estimate benefits of the interventions.

Main Outcomes and Measures  

Symptomatic infection; function, morbidity, mortality; pregnancy complications and birth outcomes.

Results  

Nineteen studies (N = 8443) meeting inclusion criteria were identified. Two cohort studies (n = 5289) found fewer cases of pyelonephritis in the cohorts of screened pregnant women (0.5%) than within retrospective comparisons of unscreened cohorts (2.2% and 1.8%); the larger study estimated a statistically significant relative risk of 0.30 (95% CI, 0.15-0.60). No studies examined screening in nonpregnant populations. Among 12 trials of asymptomatic bacteriuria screening and treatment during pregnancy (n = 2377; 1 conducted within past 30 years), there were reduced rates of pyelonephritis (range, 0%-16.5% for the intervention group and 2.2%-36.4% for the control group; pooled risk ratio [RR], 0.24 [95% CI, 0.14-0.40]; 12 trials) and low birth weight (range, 2.5%-14.8% for the intervention group and 6.7%-21.4% for the control group; pooled RR, 0.64 [95% CI, 0.46-0.90]; 7 trials). There was no significant difference in infant mortality (pooled RR, 0.98 [95% CI, 0.29-3.26]; 6 trials). Five RCTs of asymptomatic bacteriuria treatment in nonpregnant adults (n = 777) did not report any significant differences in risk of infection, mobility, or mortality. Limited evidence on harms of screening or treatment was available, and no statistically significant differences were identified.

Conclusions and Relevance  

Screening and treatment for asymptomatic bacteriuria during pregnancy was associated with reduced rates of pyelonephritis and low birth weights, but the available evidence was not current, with only 1 study conducted in the past 30 years. Benefits of asymptomatic bacteriuria treatment in nonpregnant adult populations were not found. Trial evidence on harms of asymptomatic bacteriuria antibiotic treatment was limited.

Keywords: Bacteriuria; Pregnancy.

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#Screening for Asymptomatic #Bacteriuria in #Adults – #US Preventive Services Task Force #Recommendation #Statement (JAMA, abstract)

[Source: Journal of the American Medical Association, full page: (LINK). Abstract, edited.]

US Preventive Services Task Force  / Recommendation Statement / September 24, 2019

Screening for Asymptomatic Bacteriuria in Adults – US Preventive Services Task Force Recommendation Statement

JAMA. 2019;322(12):1188-1194. doi:10.1001/jama.2019.13069

 

Abstract

Importance  

Among the general adult population, women (across all ages) have the highest prevalence of asymptomatic bacteriuria, although rates increase with age among both men and women. Asymptomatic bacteriuria is present in an estimated 1% to 6% of premenopausal women and an estimated 2% to 10% of pregnant women and is associated with pyelonephritis, one of the most common nonobstetric reasons for hospitalization in pregnant women. Among pregnant persons, pyelonephritis is associated with perinatal complications including septicemia, respiratory distress, low birth weight, and spontaneous preterm birth.

Objective  

To update its 2008 recommendation, the USPSTF commissioned a review of the evidence on potential benefits and harms of screening for and treatment of asymptomatic bacteriuria in adults, including pregnant persons.

Population  

This recommendation applies to community-dwelling adults 18 years and older and pregnant persons of any age without signs and symptoms of a urinary tract infection.

Evidence Assessment  

Based on a review of the evidence, the USPSTF concludes with moderate certainty that screening for and treatment of asymptomatic bacteriuria in pregnant persons has moderate net benefit in reducing perinatal complications. There is adequate evidence that pyelonephritis in pregnancy is associated with negative maternal outcomes and that treatment of screen-detected asymptomatic bacteriuria can reduce the incidence of pyelonephritis in pregnant persons. The USPSTF found adequate evidence of harms associated with treatment of asymptomatic bacteriuria (including adverse effects of antibiotic treatment and changes in the microbiome) to be at least small in magnitude. The USPSTF concludes with moderate certainty that screening for and treatment of asymptomatic bacteriuria in nonpregnant adults has no net benefit. The known harms associated with treatment include adverse effects of antibiotic use and changes to the microbiome. Based on these known harms, the USPSTF determined the overall harms to be at least small in this group.

Recommendations  

The USPSTF recommends screening pregnant persons for asymptomatic bacteriuria using urine culture. (B recommendation) The USPSTF recommends against screening for asymptomatic bacteriuria in nonpregnant adults. (D recommendation)

Keywords: Bacteriuria; Pregnancy.

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#Chlorhexidine for #meatal #cleaning in reducing #catheter-associated #UTIs: a multicentre stepped-wedge randomised controlled trial (Lancet Infect Dis., abstract)

[Source: The Lancet Infectious Diseases, full page: (LINK). Abstract, edited.]

Chlorhexidine for meatal cleaning in reducing catheter-associated urinary tract infections: a multicentre stepped-wedge randomised controlled trial

Oyebola Fasugba, PhD, Prof Allen C Cheng, PhD, Victoria Gregory, MSc, Prof Nicholas Graves, PhD, Jane Koerner, PhD, Prof Peter Collignon, PhD, Anne Gardner, PhD, Prof Brett G Mitchell, PhD

Published: April 12, 2019 / DOI: https://doi.org/10.1016/S1473-3099(18)30736-9

 

Summary

Background

Evidence for the benefits of antiseptic meatal cleaning in reducing catheter-associated urinary tract infection (UTI) is inconclusive. We assessed the efficacy of 0·1% chlorhexidine solution compared with normal saline for meatal cleaning before urinary catheter insertion in reducing the incidence of catheter-associated asymptomatic bacteriuria and UTI.

Methods

A cross-sectional, stepped-wedge, open-label, randomised controlled trial was undertaken in Australian hospitals. Eligible hospitals were Australian public and private hospitals, with an intensive care unit and more than 30 000 hospital admissions per year. Hospitals were randomly assigned to an intervention crossover date using a computer-generated randomisation system. Crossover dates occurred every 8 weeks; during the first 8 weeks of the study, no hospitals were exposed to the intervention (control phase), after which each hospital sequentially crossed over from the control to the intervention every 8 weeks. Patients requiring a urinary cathetwer were potentially eligible for inclusion in this hospital-wide study. Participants were excluded if they were younger than 2 years, had a medical reason preventing the use of the chlorhexidine, had the catheter inserted in theatre, did not have the catheter insertion date documented, required in-and-out or suprapubic catheterisation, had symptoms and signs suggestive of UTI at the time of catheter insertion, or were currently undergoing treatment for UTI. The intervention was the use of 0·1% chlorhexidine solution for meatal cleaning before urinary catheterisation with 0·9% normal saline used in the control phase. Masking of hospitals was not possible because it was not feasible to mask staff administering the intervention. The co-primary outcomes were the number of cases of catheter-associated asymptomatic bacteriuria and UTI per 100 catheter-days and were assessed within 7 days of catheter insertion in the intention-to-treat population. This trial is registered with Australian New Zealand Clinical Trials Registry, number ACTRN12617000373370.

Findings

21 hospitals were assessed for eligibility between Jan 5, 2017, and May 1, 2017; of these, three were successfully enrolled and randomised to one of three intervention crossover dates. 1642 participants in these hospitals were included in the study between Aug 1, 2017, and March 12, 2018, 697 (42%) in the control phase and 945 (58%) in the intervention period. In the control period, 13 catheter-associated UTI and 29 catheter-associated asymptomatic bacteriuria events in 2889 catheter-days (0·45 catheter-associated UTI cases and 1·00 catheter-associated asymptomatic bacteriuria cases per 100 catheter-days) were recorded compared with four catheter-associated UTI and 16 catheter-associated asymptomatic bacteriuria events in 2338 catheter-days (0·17 catheter-associated UTI cases and 0·68 catheter-associated asymptomatic bacteriuria cases per 100 catheter-days) during the intervention period. The intervention was associated with a 74% reduction in the incidence of catheter-associated asymptomatic bacteriuria (incident rate ratio 0·26, 95% CI 0·08–0·86, p=0·026), and a 94% decrease in the incidence of catheter-associated UTI (0·06, 95% CI 0·01–0·32, p=0·00080). There were no reported adverse events.

Interpretation

The use of chlorhexidine solution for meatal cleaning before catheter insertion decreased the incidence of catheter-associated asymptomatic bacteriuria and UTI and has the potential to improve patient safety.

Funding

HCF Research Foundation.

Keywords: Chlorhexidine; UTIs; Bacteriuria.

—–

Effect of #Cranberry Capsules on #Bacteriuria Plus #Pyuria Among Older #Women in #NursingHomes – A Randomized Clinical Trial (JAMA, abstract)

[Source: JAMA, full page: (LINK). Abstract, edited.]

Original Investigation  / October 27, 2016

Effect of Cranberry Capsules on Bacteriuria Plus Pyuria Among Older Women in Nursing Homes – A Randomized Clinical Trial

Manisha Juthani-Mehta, MD1; Peter H. Van Ness, PhD, MPH2; Luann Bianco, BA2; et al
Andrea Rink, RN2; Sabina Rubeck, MPH2; Sandra Ginter, BSN2; Stephanie Argraves, MS2; Peter Charpentier, MPH2; Denise Acampora, MPH2; Mark Trentalange, MD, MPH2; Vincent Quagliarello, MD1; Peter Peduzzi, PhD3

Author Affiliations: 1Section of Infectious Diseases, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut; 2Section of Geriatrics, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut; 3Yale Center for Analytical Sciences, Department of Biostatistics, Yale School of Public Health, New Haven, Connecticut

Copyright 2016 American Medical Association. All Rights Reserved.

JAMA. Published online October 27, 2016. doi:10.1001/jama.2016.16141

 

Key Points

  • Question   – Do cranberry capsules with sufficient proanthocyanidin content affect the presence of bacteriuria plus pyuria in older women living in nursing homes?
  • Findings  – In this randomized clinical trial of 185 women nursing home residents, after adjusting for missing data and covariates, there was no statistically significant difference in presence of bacteriuria plus pyuria between the treatment (29.1%) and control (29.0%) groups over 1 year.
  • Meaning  – Among older women living in nursing homes, cranberry capsules, compared with placebo, did not have a significant effect on the presence of bacteriuria plus pyuria over 1 year.

 

Abstract

Importance 

Bacteriuria plus pyuria is highly prevalent among older women living in nursing homes. Cranberry capsules are an understudied, nonantimicrobial prevention strategy used in this population.

Objective 

To test the effect of 2 oral cranberry capsules once a day on presence of bacteriuria plus pyuria among women residing in nursing homes.

Design, Setting, and Participants 

Double-blind, randomized, placebo-controlled efficacy trial with stratification by nursing home and involving 185 English-speaking women aged 65 years or older, with or without bacteriuria plus pyuria at baseline, residing in 21 nursing homes located within 50 miles (80 km) of New Haven, Connecticut (August 24, 2012-October 26, 2015).

Interventions 

Two oral cranberry capsules, each capsule containing 36 mg of the active ingredient proanthocyanidin (ie, 72 mg total, equivalent to 20 ounces of cranberry juice) vs placebo administered once a day in 92 treatment and 93 control group participants.

Main Outcomes and Measures 

Presence of bacteriuria (ie, at least 105 colony-forming units [CFUs] per milliliter of 1 or 2 microorganisms in urine culture) plus pyuria (ie, any number of white blood cells on urinalysis) assessed every 2 months over the 1-year study surveillance; any positive finding was considered to meet the primary outcome. Secondary outcomes were symptomatic urinary tract infection (UTI), all-cause death, all-cause hospitalization, all multidrug antibiotic–resistant organisms, antibiotics administered for suspected UTI, and total antimicrobial administration.

Results 

Of the 185 randomized study participants (mean age, 86.4 years [SD, 8.2], 90.3% white, 31.4% with bacteriuria plus pyuria at baseline), 147 completed the study. Overall adherence was 80.1%. Unadjusted results showed the presence of bacteriuria plus pyuria in 25.5% (95% CI, 18.6%-33.9%) of the treatment group and in 29.5% (95% CI, 22.2%-37.9%) of the control group. The adjusted generalized estimating equations model that accounted for missing data and covariates showed no significant difference in the presence of bacteriuria plus pyuria between the treatment group vs the control group (29.1% vs 29.0%; OR, 1.01; 95% CI, 0.61-1.66; P = .98). There were no significant differences in number of symptomatic UTIs (10 episodes in the treatment group vs 12 in the control group), rates of death (17 vs 16 deaths; 20.4 vs 19.1 deaths/100 person-years; rate ratio [RR], 1.07; 95% CI, 0.54-2.12), hospitalization (33 vs 50 admissions; 39.7 vs 59.6 hospitalizations/100 person-years; RR, 0.67; 95% CI, 0.32-1.40), bacteriuria associated with multidrug-resistant gram-negative bacilli (9 vs 24 episodes; 10.8 vs 28.6 episodes/100 person-years; RR, 0.38; 95% CI, 0.10-1.46), antibiotics administered for suspected UTIs (692 vs 909 antibiotic days; 8.3 vs 10.8 antibiotic days/person-year; RR, 0.77; 95% CI, 0.44-1.33), or total antimicrobial utilization (1415 vs 1883 antimicrobial days; 17.0 vs 22.4 antimicrobial days/person-year; RR, 0.76; 95% CI, 0.46-1.25).

Conclusions and Relevance 

Among older women residing in nursing homes, administration of cranberry capsules vs placebo resulted in no significant difference in presence of bacteriuria plus pyuria over 1 year.

Trial Registration  clinicaltrials.gov Identifier: NCT01691430

Keywords: Cranberry capsules; Bacteriuria.

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#Effect of #body #surface #decolonisation on #bacteriuria and #candiduria in #ICUs: an analysis of a cluster-randomised trial (The Lancet Infect Dis., abstract)

[Source: The Lancet Infectious Diseases, full page: (LINK). Abstract, edited.]

Articles

Effect of body surface decolonisation on bacteriuria and candiduria in intensive care units: an analysis of a cluster-randomised trial [      ]

Susan S Huang, Edward Septimus, Mary K Hayden, Ken Kleinman, Jessica Sturtevant, Taliser R Avery, Julia Moody, Jason Hickok, Julie Lankiewicz, Adrijana Gombosev, Rebecca E Kaganov, Katherine Haffenreffer, John A Jernigan, Jonathan B Perlin, Richard Platt, Robert A Weinstein, for the Agency for Healthcare Research and Quality (AHRQ) DEcIDE Network and Healthcare-Associated Infections Program, and the CDC Prevention Epicenters Program

Published Online: 26 November 2015 / Publication stage: In Press Corrected Proof / DOI: http://dx.doi.org/10.1016/S1473-3099(15)00238-8

© 2015 Elsevier Ltd. All rights reserved.

 

Summary

Background

Urinary tract infections (UTIs) are common health-care-associated infections. Bacteriuria commonly precedes UTI and is often treated with antibiotics, particularly in hospital intensive care units (ICUs). In 2013, a cluster-randomised trial (REDUCE MRSA Trial [Randomized Evaluation of Decolonization vs Universal Clearance to Eradicate MRSA]) showed that body surface decolonisation reduced all-pathogen bloodstream infections. We aim to further assess the effect of decolonisation on bacteriuria and candiduria in patients admitted to ICUs.

Methods

We did a secondary analysis of a three-group, cluster-randomised trial of 43 hospitals (clusters) with patients in 74 adult ICUs. The three groups included were either meticillin-resistant Staphylococcus aureus (MRSA) screening and isolation, targeted decolonisation (screening, isolation, and decolonisation of MRSA carriers) with chlorhexidine and mupirocin, and universal decolonisation (no screening, all patients decolonised) with chlorhexidine and mupirocin. Protocol included chlorhexidine cleansing of the perineum and proximal 6 inches (15·24 cm) of urinary catheters. ICUs within the same hospital were assigned the same strategy. Outcomes included high-level bacteriuria (≥50 000 colony forming units [CFU]/mL) with any uropathogen, high-level candiduria (≥50 000 CFU/mL), and any bacteriuria with uropathogens. Sex-specific analyses were specified a priori. Proportional hazards models assessed differences in outcome reductions across groups, comparing an 18-month intervention period to a 12-month baseline period.

Findings

122 646 patients (48 390 baseline, 74 256 intervention) were enrolled. Intervention versus baseline hazard ratios (HRs) for high-level bacteriuria were 1·02 (95% CI 0·88–1·18) for screening or isolation, 0·88 (0·76–1·02) for targeted decolonisation, and 0·87 (0·77–1·00) for universal decolonisation (no difference between groups, p=0·26), with no sex-specific reductions (HRs for men: 1·09 [95% CI 0·85–1·40] for screening or isolation, 1·01 [0·79–1·29] for targeted decolonisation, and 0·78 [0·63–0·98] for universal decolonisation, p=0·12; HRs for women: 0·97 [0·80–1·17] for screening and isolation, 0·83 [0·70–1·00] for targeted decolonisation, and 0·93 [0·79–1·09] for universal decolonisation, p=0·49). HRs for high-level candiduria were 1·14 (0·95–1·37) for screening and isolation, 0·99 (0·83–1·18) for targeted decolonisation, and 0·83 (0·70–0·99) for universal decolonisation (p=0·05). Differences between sexes were due to reductions in men in the universal decolonisation group (HRs: 1·21 [95% CI 0·88–1·68] for screening or isolation, 1·01 [0·73–1·39] for targeted decolonisation, and 0·63 [0·45–0·89] for universal decolonisation, p=0·02). Bacteriuria with any CFU/mL was also reduced in men in the universal decolonisation group (HRs 1·01 [0·81–1·25] for screening or isolation, 1·04 [0·83–1·30] for targeted decolonisation, and 0·74 [0·61–0·90] for universal decolonisation, p=0·04).

Interpretation

Universal decolonisation of patients in the ICU with once a day chlorhexidine baths and short-course nasal mupirocin could be a potential preventive strategy in male patients because it significantly decreases candiduria and any bacteriuria, but not for women.

Funding

HAI Program from AHRQ, US Department of Health and Human Services as part of the Developing Evidence to Inform Decisions about Effectiveness (DEcIDE) program, CDC Prevention Epicenters Program.

Keywords: Research; Abstracts; Bacteriuria; Candiduria.

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