Evaluation of the Diagnosis and Antibiotic Prescription Pattern in Patients Hospitalized with Urinary Tract Infections: Single-Center Study from a University-Affiliated Hospital
Abstract
:1. Introduction
2. Results
2.1. Patient Characteristics and Main Outcomes
2.2. Diagnosis of UTIs
2.3. EAU-Confirmed UTIs and Most Frequently Isolated Pathogen Species
2.4. Antibiotic Therapy for EAU-Confirmed UTIs
2.5. Guideline Adherence in EAU-Confirmed UTIs
3. Discussion
3.1. Diagnosis
3.2. Guideline Adherent Empirical Antibiotic Therapy
3.2.1. Guideline Adherence: Agent Selection
3.2.2. Guideline Adherence: Dosage and Duration of Antibiotic Therapy
3.3. Changes in the First Empirical Therapy
3.4. Strengths and Limitations
4. Materials and Methods
4.1. Study Design and Setting
4.2. Data Collection
4.3. Main Outcome Measures
4.4. Statistical Analyses
5. Conclusions
Author Contributions
Funding
Institutional Review Board Statement
Informed Consent Statement
Data Availability Statement
Acknowledgments
Conflicts of Interest
Appendix A
Types of UTIs | uc-Cystitis | uc-Pyelonephritis | cUTI without Pyelonephriti | cUTI with Pyelonephritis | Urosepsis |
---|---|---|---|---|---|
Risk Factors | |||||
No known relevant anatomical and functional abnormalities within the urinary tract, indwelling urinary catheters, renal diseases, obstruction | ✓ | ✓ | |||
No comorbidities 1 | ✓ | ✓ | |||
Age (over 65 years old) | ✓ | ✓ | |||
Pregnancy | ✓ | ✓ | |||
Men | ✓ | ✓ | |||
Known relevant anatomical and functional abnormalities within the urinary tract, indwelling urinary catheters, renal diseases, obstruction | ✓ | ✓ | ✓ | ||
Comorbidities 1 | ✓ | ✓ | ✓ | ||
Recent history of HAI 2 | ✓ | ✓ | ✓ | ||
SIRS, life-threatening organ dysfunction 3 | ✓ | ||||
Potential signs and symptoms | |||||
Lower urinary tract: dysuria, frequency, urgency | ✓ | ✓ | ✓ | ✓ | |
Absence of vaginal discharge or irritation | ✓ | ||||
Fever (>38 °C) | ✓ | ✓ | ✓ | ✓ | |
Hypothermia | ✓ | ||||
Chills, suprapubic pain | ✓ | ✓ | ✓ | ||
Chills, flank pain | ✓ | ||||
Nausea, vomiting | ✓ | ✓ | ✓ | ||
Costovertebral angle tenderness | ✓ | ✓ | ✓ | ||
Bacteriuria, pyuria | ✓ | ✓ | ✓ | ||
Tachycardia and tachypnoea | ✓ | ||||
Differential diagnosis | |||||
Imaging technique 4 | ✓ | ✓ | |||
Laboratory diagnosis | |||||
Urinalysis (assessment of white and red blood cells and nitrite) 5 | ✓ | ✓ | |||
Urine culture and antimicrobial susceptibility testing 5 | ✓ | ✓ | ✓ | ✓ | |
Blood culture | ✓ | ||||
CBC (leukocytosis or leukopenia) | ✓ | ||||
Rise in the level of PCT | ✓ | ||||
Rise in the level of Serum lactate | ✓ |
Appendix B
Antimicrobial Agent | Appropriate (Recommended) Dose | Recommended Dose Adjustment by SPC | Debatable Dose | Underdose/Overdose | |
---|---|---|---|---|---|
EAU UTI Guideline 1 | eGFR (mL/min) | Body Weight (kg) | |||
Fosfomycin trometamol | oral 3 g SD | <10 | <50% deviation from the recommended dose and/or absence of loading dose | ≥50% deviation from the recommended dose and/or no dose adjustment in renal impairment and in extremes 2 for body weight | |
Nitrofurantoin monohydrate | oral 100 mg b.i.d | ≤50 | |||
Amoxicillin/clavulanic acid | oral 375 mg t.i.d | <10 | <50 kg | ||
Amoxicillin/clavulanic acid | oral 625 mg t.i.d | <10 | <50 kg | ||
Amoxicillin/clavulanic acid | iv 1.2 g t.i.d | <10 | <50 kg | ||
Cefuroxim axetil | oral 500 mg b.i.d | <20 | |||
Cefuroxim sodium | iv 0.75–1.5 g b.i.d-t.i.d | <20 | |||
Trimethoprim/sulphametoxazole | oral 160/800 mg b.i.d | <30 | |||
Ofloxacin | oral 200 mg b.i.d | <50 | |||
Norfloxacin | oral 400 mg b.i.d | <20 | |||
Ciprofloxacin | oral 500–750 mg b.i.d or iv 400 mg b.i.d | <30 | |||
Levofloxacin | oral 750 mg q.d iv 500 mg q.d | <50 | |||
Cefotaxime | iv 2 g t.i.d | <5 | |||
Ceftriaxone | iv 1–2 g q.d | <10 | <50 kg | ||
Cefepime | iv 1–2 g q.d | <50 | <40 kg | ||
Piperacillin/tazobactam | iv 2.5–4.5 g t.i.d | <50 | |||
Gentamicin | iv 5 mg/kg q.d | <40 | 5 mg/bodyweight | ||
Amikacin | iv 15 mg/kg q.d | <70 | 5 mg/bodyweight | ||
Imipenem/cilastatin | iv 0.5 g t.i.d | <70 | |||
Meropenem | iv 1 g t.i.d | <50 |
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Parameters | N | % |
---|---|---|
185 | 100 | |
Gender (female) | 125 | 67.6 |
Age (years) (mean ± SD, range) | 71.87 ± 15.04 (21–101) | |
20–64 years | 52 | 28.1 |
65+ years | 133 | 71.9 |
CCI (Charlson Comorbidity Index) (mean ± SD, range) | 4.71 ± 1.96 (0–11) | |
0 | 7 | 3.78 |
1 | 1 | 0.5 |
2 | 12 | 6.5 |
3 | 28 | 15.1 |
4 | 33 | 17.8 |
>4 | 104 | 56.2 |
Comorbidities | ||
Cardiovascular disease * | 46 | 24.9 |
Diabetes mellitus | 45 | 24.3 |
Chronic kidney disease (moderate to severe) | 25 | 13.5 |
Chronic liver disease (moderate to severe) | 24 | 13.0 |
Hematological malignant diseases | 23 | 12.4 |
Solid tumor | 18 | 9.7 |
Localized | 16 | 8.6 |
Metastatic | 2 | 1.1 |
Dementia | 17 | 9.2 |
Cerebrovascular accident or transient ischemic attack | 15 | 8.1 |
Peptic ulcer disease | 14 | 7.6 |
Chronic obstructive pulmonary disease | 8 | 4.3 |
Peripheral vascular disease | 1 | 0.5 |
Discharge types | ||
Discharged home | 160 | 86.5 |
Other hospital ward | 4 | 2.2 |
ICU (intensive care unit) | 7 | 3.8 |
LTCF (long-term care facility) | 1 | 0.5 |
Outcome | ||
In-hospital mortality | 13 | 7.0 |
30-day mortality | 17 | 9.2 |
Recorded Diagnosis | EAU-Confirmed Diagnosis |
---|---|
Total (n = 185), 100% | |
Cystitis (n = 10), 5.4% | ucUTI (n = 3) cUTI (n = 5) ABU (n = 1) Misdiagnosis (n = 1) |
Pyelonephritis (n = 9), 3.8% | ucUTI (n = 4) cUTI (n = 3) Misdiagnosis (n = 2) |
Urosepsis (n = 18), 9.7% | ucUTI (n = 7) cUTI (n = 4) ABU (n = 2) Unconfirmed urosespsis (n = 5) |
UTI (n = 148), 80.0% | ucUTI (n = 46) * cUTI (n = 36) ABU (n = 23) Misdiagnosis (n = 43) |
Total: ucUTI (n = 60) *, 32.4% cUTI (n = 48), 25.9% ABU (n =26), 14.1% Unconfirmed urosepsis (n = 5), 2.7% Misdiagnosis (n = 46), 24.9% |
Pathogens | ucUTI (Cystitis) N = 1 | ucUTI (Pyelonephritis) N = 59 (%) | cUTI (Pyelonephritis) N = 48 (%) | Total N = 108 (%) |
---|---|---|---|---|
Total urine cultures | - | 30 (50.8%) | 25 (52.1%) | 55 (50.9%) |
Positive urine cultures | - | 23 (39.0%) | 20 (41.7%) | 43 (39.8%) |
Contaminated sample | - | 2 (3.4%) | 1 (2.1%) | 3 (2.8%) |
From positive urine cultures (%) | ||||
More than one pathogen per sample | - | 6 (26.12%) | 2 (10.0%) | 8 (18.6%) |
Esherchia coli | - | 10 (43.5%) | 9 (45.0%) | 19 (44.2%) |
Klebsiella spp. | - | 4 (17.4%) | 2 (10.0%) | 6 (14.0%) |
Other Enterobacteriaceae spp. | - | 4 (17.4%) | 1 (5.0%) | 5 (11.6%) |
Enterococcus faecalis | - | 1 (4.3%) | 4 (20.0%) | 5 (11.6%) |
Pseudomonas spp. | - | 1 (4.3%) | 3 (15.0%) | 4 (9.3%) |
Proteus spp. | - | 1 (4.3%) | - | 1 (2.3%) |
Streptococcus spp. | - | 1 (4.3%) | - | 1 (2.3%) |
Candida spp. | - | 4 (17.4%) | 3 (15.0%) | 7 (16.3%) |
MDR bacteria | - | 3 (13.0%) | - | 3 (7.0%) |
Parameters | N | % |
---|---|---|
108 | 100 | |
EAU guideline-adherent agent(s) | 49 | 45.4 |
EAU guideline adherent agent(s) and route of administration | 49 | 45.4 |
EAU guideline adherent agent(s), route of administration, and dose | 39 | 36.1 |
EAU guideline adherent agent(s), route of administration, dose, and duration | 11 | 10.2 |
Type of the first antibiotic therapy | ||
Monotherapies | 82 | 75.9 |
Combination therapies | 26 | 24.1 |
Route of administration of the first antibiotic therapy | ||
intravenous | 66 | 61.1 |
oral | 42 | 38.9 |
Dosage of the first antibiotic therapy for guideline adherent agent selection | ||
appropriate | 39 | 36.1 |
overdosed (compared to SPC due to lack of guideline recommended dose) | 0 | 0.0 |
underdosed (compared to EAU guideline and due to body weight) | 10 | 9.3 |
Duration of total antibiotic therapies (Mean ± SD, range) 6.59 ± 5.21 (1–35) | ||
Total antibiotic exposure (Mean ± SD, DDD/patient) 9.84 ± 14.99 (0.50–72.47) | ||
Number of consecutive antibiotic therapies | ||
1 | 69 | 63.9 |
>1 (2–5) | 39 | 36.1 |
Changes in the first empirical therapy | ||
Sequential antibiotic therapy * | 7 | 6.5 |
De-escalation | 6 | 5.6 |
Escalation | 28 | 25.9 |
No change | 67 | 62.0 |
Antibiotics | Route of Administration 4 | Doses/Day | Frequency (N) | Total % | EAU Guideline Adherence 4 | |||||
---|---|---|---|---|---|---|---|---|---|---|
Guideline Adherence % | uc-Cystitis (n = 1) | uc-Pyelonephritis (n = 59) | cUTI without Pyelonephritis (n = 0) | cUTI with Pyelonephritis (n = 48) | Rosepsis (n = 0) | |||||
Monotherapies (N = 82; 100%) | ||||||||||
Fosfomycin trometamol | po | 3 g q.d | 1 | 1.2 | 0.0 | 1 | ||||
Nitrofurantoin monohydrate | po | 100 mg b.i.d-t.i.d | 2 | 2.4 | 0.0 | 1 | 1 | |||
Amoxicillin/clavulanic acid | po | 625 mg b.i.d-t.i.d | 12 | 14.6 | 11.0 | 1 | 9 | 2 | ||
Amoxicillin/clavulanic acid | iv | 1.2 g b.i.d-t.i.d | 24 | 29.3 | 29.3 | 14 | 10 | |||
Ceftibuten | po | - | 0 | 0.0 | 0.0 | |||||
Cefuroxim axetil | po | - | 0 | 0.0 | 0.0 | |||||
Cefuroxim sodium | iv | - | 0 | 0.0 | 0.0 | |||||
Trimethoprim-sulphamethoxazole 1 | po | 400–800/80–160 mg b.i.d | 3 | 3.7 | 0.0 | 3 | ||||
Ofloxacin | po | - | 0 | 0.0 | 0.0 | |||||
Norfloxacin | po | 400 mg b.i.d | 3 | 3.7 | 1.2 | 1 | 2 | |||
Ciprofloxacin 2 | po | 500 mg b.i.d | 12 | 14.6 | 14.6 | 7 | 5 | |||
Ciprofloxacin 2 | iv | 400 mg b.i.d | 3 | 3.7 | 3.7 | 1 | 2 | |||
Levofloxacin 2 | po | 500 mg q.d | 2 | 2.4 | 2.4 | 2 | ||||
Levofloxacin 2 | iv | - | 0 | 0.0 | 0.0 | |||||
Cefotaxime | iv | - | 0 | 0.0 | 0.0 | |||||
Ceftriaxone | iv | 2 g q.d | 12 | 14.6 | 14.6 | 5 | 7 | |||
Cefepime | iv | - | 0 | 0.0 | 0.0 | |||||
Piperacillin/tazobactam | iv | - | 0 | 0.0 | 0.0 | |||||
Imipenem/cilastatin | iv | - | 0 | 0.0 | 0.0 | |||||
Meropenem | iv | 500 mg t.i.d- 1 g b.i.d | 4 | 4.9 | 2.4 | 2 | 2 | |||
Clarithromycin | po | 500 mg b.i.d | 1 | 1.2 | 0.0 | 1 | ||||
Gentamicin monotherapy | iv | 80–120 mg q.d | 2 | 2.4 | 0.0 | 2 | ||||
Moxifloxacin | po | 400 mg q.d | 1 | 1.2 | 0.0 | 1 | ||||
Combination therapies (N = 26; 100%) | ||||||||||
Amoxicillin-clavulanic acid + amikacin/gentamicin 3 | iv | 1.2 g t.i.d + 80 mg b.i.d | 1 | 3.8 | 0.0 | 1 | ||||
Ceftriaxone + amikacin/gentamicin 3 | iv | - | 0 | 0.0 | 0.0 | |||||
Piperacillin/tazobactam + amikacin/gentamicin 3 | iv | - | 0 | 0.0 | 0.0 | |||||
Meropenem + amikacin/gentamicin 3 | iv | - | 0 | 0.0 | 0.0 | |||||
Imipenem-cilastatin + amikacin/gentamicin 3 | iv | - | 0 | 0.0 | 0.0 | |||||
Amoxicillin-clavulanic acid + clarithromycin | iv | 1.2 g t.i.d + 500 mg b.i.d | 1 | 3.8 | 0.0 | 1 | ||||
Amoxicillin-clavulanic acid + metronidazole | iv + po | 1.2 g b.i.d-t.i.d + 500 mg b.i.d | 4 | 15.4 | 0.0 | 1 | 3 | |||
Amoxicillin-clavulanic acid + metronidazole | po | 625 mg b.i.d-t.i.d + 500 mg b.i.d | 2 | 7.7 | 0.0 | 2 | ||||
Amoxicillin-clavulanic acid + Trimethoprim-sulphamethoxazole | iv + po | 1.2 g t.i.d + 400/80 mg b.i.d | 1 | 3.8 | 0.0 | 1 | ||||
Ceftriaxone + metronidazole | iv | 2 g q.d + 250–500 mg b.i.d | 5 | 19.2 | 0.0 | 4 | 1 | |||
Ceftriaxone + metronidazole | iv + po | 2 g q.d + 500 mg b.i.d | 2 | 7.7 | 0.0 | 2 | ||||
Ceftriaxone + trimethoprim-sulphamethoxazole | iv + po | 500 mg b.i.d–2 g q.d + 400/80 mg b.i.d | 2 | 7.7 | 0.0 | 1 | 1 | |||
Ciprofloxacin + metronidazole | po | 500 mg b.i.d + 500 mg b.i.d | 2 | 7.7 | 0.0 | 1 | 1 | |||
Ciprofloxacin + moxifloxacin | iv + po | 500 mg b.i.d + 400 mg q.d | 1 | 3.8 | 0.0 | 1 | ||||
Ciprofloxacin + tobramycin | iv | 500 mg b.i.d + 80 mg b.i.d | 1 | 3.8 | 0.0 | 1 | ||||
Nitrofurantoin + metronidazole | po | 100 mg t.i.d + 500 mg b.i.d | 2 | 7.7 | 0.0 | 1 | 1 | |||
Imipenem + metronidazole | iv + po | 1 g t.i.d + 500 mg b.i.d | 1 | 3.8 | 0.0 | 1 | ||||
Tygecyclin + colomycin | iv | 400 mg q.d + 1 IU t.i.d | 1 | 3.8 | 0.0 | 1 |
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Fésüs, A.; Matuz, M.; Papfalvi, E.; Hambalek, H.; Ruzsa, R.; Tánczos, B.; Bácskay, I.; Lekli, I.; Illés, Á.; Benkő, R. Evaluation of the Diagnosis and Antibiotic Prescription Pattern in Patients Hospitalized with Urinary Tract Infections: Single-Center Study from a University-Affiliated Hospital. Antibiotics 2023, 12, 1689. https://doi.org/10.3390/antibiotics12121689
Fésüs A, Matuz M, Papfalvi E, Hambalek H, Ruzsa R, Tánczos B, Bácskay I, Lekli I, Illés Á, Benkő R. Evaluation of the Diagnosis and Antibiotic Prescription Pattern in Patients Hospitalized with Urinary Tract Infections: Single-Center Study from a University-Affiliated Hospital. Antibiotics. 2023; 12(12):1689. https://doi.org/10.3390/antibiotics12121689
Chicago/Turabian StyleFésüs, Adina, Mária Matuz, Erika Papfalvi, Helga Hambalek, Roxána Ruzsa, Bence Tánczos, Ildikó Bácskay, István Lekli, Árpád Illés, and Ria Benkő. 2023. "Evaluation of the Diagnosis and Antibiotic Prescription Pattern in Patients Hospitalized with Urinary Tract Infections: Single-Center Study from a University-Affiliated Hospital" Antibiotics 12, no. 12: 1689. https://doi.org/10.3390/antibiotics12121689