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Optimal Urine Culture Diagnostic Stewardship Practice-Results from an Expert Modified-Delphi Procedure

Author/s: 
Claeys, K. C., Trautner, B. W., Leekha, S., Coffey, K. C., Crnich, C. J., Diekema, D. J., Fakih, M. G., Goetz, M. B., Gupta, K., Jones, M. M., Leykum, L., Liang, S. Y., Pineles, L., Pleiss, A., Spivak, E. S., Suda, K. J., Taylor, J. M., Rhee, C., Morgan, D. J.

Background: Urine cultures are nonspecific and often lead to misdiagnosis of urinary tract infection and unnecessary antibiotics. Diagnostic stewardship is a set of procedures that modifies test ordering, processing, and reporting in order to optimize diagnosis and downstream treatment. In this study, we aimed to develop expert guidance on best practices for urine culture diagnostic stewardship.

Methods: A RAND-modified Delphi approach with a multidisciplinary expert panel was used to ascertain diagnostic stewardship best practices. Clinical questions to guide recommendations were grouped into three thematic areas (ordering, processing, reporting) in practice settings of emergency department, inpatient, ambulatory, and long-term care. Fifteen experts ranked recommendations on a 9-point Likert scale. Recommendations on which the panel did not reach agreement were discussed during a virtual meeting, then a second round of ranking by email was completed. After secondary review of results and panel discussion, a series of guidance statements was developed.

Results: One hundred and sixty-five questions were reviewed. The panel reaching agreement on 104, leading to 18 overarching guidance statements. The following strategies were recommended to optimize ordering urine cultures: requiring documentation of symptoms, sending alerts to discourage ordering in the absence of symptoms, and cancelling repeat cultures. For urine culture processing, conditional urine cultures and urine white blood cell count as criteria were supported. For urine culture reporting, appropriate practices included nudges to discourage treatment under specific conditions and selective reporting of antibiotics to guide therapy decisions.

Conclusions: These 18 guidance statements can optimize use of urine cultures for better patient outcomes.

Keywords: diagnostic stewardship; expert consensus; modified Delphi; urinary tract infection; urine cultures.

Keywords 
Diagnostic Stewardship Expert consensus modified Delphi urinary tract infections urine cultures

Nonsurgical Treatments for Urinary Incontinence in Women: A Systematic Review Update

Author/s: 
Balk, Ethan, Adam, Gaelen P., Kimmel, Hannah, Rofeberg, Valerie, Saeed, Iman, Jeppson, Peter, Trikalinos, Thomas

Introduction. About 17 percent of adult women have had urinary incontinence (UI), classified as stress, urgency, or mixed. Stress UI is associated with an inability to retain urine with activities that increase intraabdominal pressure. Urgency UI is associated with the sudden, compelling urge to void. Mixed UI occurs when both are present.

Methods. We updated the Agency for Healthcare Research and Quality's 2012 systematic review with new literature searches in MEDLINE®, the Cochrane Central Trials Registry, the Cochrane Database of Systematic Reviews, and Embase® from 2011 through December 4, 2017. We included UI outcomes (cure, improvement, satisfaction), quality of life, and adverse events. For UI outcomes, we conducted network meta-analyses, combining direct and indirect comparisons across studies. Quality of life and adverse event outcomes are narratively described.

Results. We identified 233 eligible studies, of which 140 reported on UI outcomes, 96 on quality of life, and 127 on adverse events. Studies evaluated 16 categories of interventions with 53 specific interventions. Fourteen intervention categories have been evaluated for UI outcomes; all except hormones and periurethral bulking agents were more effective to achieve at least one favorable UI outcome than no treatment (variable strength of evidence [SoE]). Among 1st or 2nd line interventions for stress UI, behavioral therapy (BT, alone and in combination with hormones) was more effective than either alpha agonists or hormones to achieve cure or improvement (moderate SoE); alpha agonists were more effective than hormones to achieve improvement (moderate SoE). Among treatments used as 1st or 2nd line interventions for urgency UI, BT was significantly more effective than anticholinergics to achieve cure or improvement (high SoE). Among 3rd line interventions for stress UI, intravesical pressure release, but not periurethral bulking agents, was more effective than no treatment (variable SoE). Neuromodulation, which is commonly used for treatment of urgency UI, is more effective than no treatment of stress UI for cure, improvement, and satisfaction (high SoE). Among studies of women with only stress UI, indirect evidence suggests that intravesical pressure release is more effective to achieve improvement than combination BT and neuromodulation, and triple combination neuromodulation, hormones, and BT may be more effective than either periurethral bulking or combination neuromodulation and BT (all low SoE). Among treatments used as 3rd line interventions for urgency UI, both neuromodulation and onabotulinum toxin A (BTX) are more effective than no treatment (high SoE), and BTX may be more effective than neuromodulation to achieve cure (low SoE). BT, neuromodulation, and anticholinergics resulted in better quality of life than no treatment (low SoE). Urinary tract infections (UTIs) were reported in 11 percent of women receiving transcutaneous electrical nerve stimulation and erosion in 1.6 percent of women with the periurethral bulking agent macroplastique (low SoE). Dry mouth was the most commonly reported adverse event for the anticholinergic oxybutynin (36%) and the alpha agonist duloxetine (13%) (high SoE). BTX was associated with UTIs (36%) and urinary retention (10% to 20%) (moderate SoE). Constitutional adverse events (e.g., nausea, insomnia, fatigue) were common with duloxetine (moderate SoE).

Conclusions. Network meta-analyses demonstrated that most nonpharmacological and pharmacological interventions are more likely than no treatment to improve UI outcomes and quality of life. BT, alone or in combination with other interventions, is generally more effective than 2nd line (pharmacological) therapies alone for both stress and urgency UI. Common adverse events with pharmacological treatments include dry mouth, nausea, and fatigue. BTX is associated with urinary infections and retention. Periurethral bulking agents are associated with erosion and need for surgical removal. Large gaps remain in the literature regarding head-to-head comparisons of individual interventions.

Keywords 
urinary tract infections behavior therapy urinary incontinence
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