Point-of-care urine Gram stain led to narrower-spectrum antimicrobial selection for febrile urinary tract infection in adolescents and adults

Abstract

Background Febrile urinary tract infections (fUTIs), which include pyelonephritis, prostatitis, and urosepsis, are the most common cause of sepsis. However, the treatment has become more complex because of the worldwide increase in antimicrobial resistance (AMR). The objective of this study was to clarify whether point-of-care Gram stain (PCGS) of urine contributed to fUTI diagnosis and treatment in adults. Methods This hospital-based observational study was undertaken between January 2013 and March 2015 in Okinawa, Japan. All enrolled patients were adults who had been admitted to the Division of Infectious Diseases with suspected fUTI. The usefulness of PCGS results were compared for urinalysis (U/A) and urine cultures (U/Cs). The targeted therapy type and its susceptibility based on PCGS were analyzed, and each was investigated in two groups: the uncomplicated pyelonephritis group and the complicated pyelonephritis/prostatitis group. Results Two hundred and sixty-six patients were enrolled. The results of PCGS were closely correlated with those of U/A for pyuria and bacteriuria, and moderately correlated with the results of U/C for bacterial types. In the uncomplicated group, narrow-spectrum antimicrobials such as cefotiam were initially selected in 97.9% (47/48) of patients, and their susceptibility was 97.9% (47/48). In the complicated group, the susceptibility was 84.2% (186/221) (p = 0.009) despite frequent AMRs (14.7%; 32/218) and low use of broad-spectrum antimicrobials such as carbapenems (7.7%; 17/221). Conclusion Urine PCGS led to a more precise fUTI diagnosis and prompted clinicians to select narrower-spectrum antibiotics with high susceptibility.

Can Gram staining be a guiding tool for optimizing initial antimicrobial agents in bacterial infections?

“…After Okinawa was returned to Japan in 1972, the program continued, and Gram staining has remained an important procedure in the clinical practice of infectious diseases performed by physicians at Okinawa Chubu Hospital. In fact, many studies on the usefulness of Gram staining have been reported by physicians at this hospital 16–20 . Furthermore, postgraduate mandatory clinical residency training that began in Japan in 2004 has spread this concept to medical institutions other than Okinawa Chubu Hospital.…”

“…In fact, many studies on the usefulness of Gram staining have been reported by physicians at this hospital. [16][17][18][19][20] Furthermore, postgraduate mandatory clinical residency training that began in Japan in 2004 has spread F I G U R E 1 Differences between Gram-stain guided antimicrobial therapy and general antimicrobial therapy. GNR, Gram-negative rods; GPB, Gram-positive bacilli; GPC, Gram-positive cocci.…”

“…The efficacy of Gram staining as point-of-care testing performed by physicians in the ER has been evaluated for infections commonly encountered in the ER, such as pneumonia, 16,17 urinary tract infections, [17][18][19] and skin and soft tissue infections, 17 and for meningitis, 20 a serious infection (Table 1). Taniguchi et al 17 compared the selection of antimicrobials based on Gram staining by physicians to selection based on Japanese guideline recommendations for bacterial infections diagnosed in the ER.…”

Diagnostic Accuracy of Point-of-Care Gram Stains in Obstructive Pyelonephritis due to Ureteral Stones

“…As a form of point-of-care (POC) testing, urine Gram stains have been proven invaluable for the prompt diagnosis of urinary tract infection (UTI) [ 10 , 11 ]. POC Gram stain (PCGS) of urine showed a moderate correlation and high agreement with urine culture in both uncomplicated and complicated UTI [ 10 ].…”

“…As a form of point-of-care (POC) testing, urine Gram stains have been proven invaluable for the prompt diagnosis of urinary tract infection (UTI) [ 10 , 11 ]. POC Gram stain (PCGS) of urine showed a moderate correlation and high agreement with urine culture in both uncomplicated and complicated UTI [ 10 ]. Despite limited data on clinical efficacy, previous studies have indicated that PCGS for both uncomplicated and complicated UTIs yields comparable treatment success rates to guideline-based therapy while also reducing the cost of broad-spectrum antimicrobials [ 12 ].…”