Infection Control & Hospital Epidemiology (2019), 40,470–472 doi:10.1017/ice.2019.22
Concise Communication
Antimicrobial therapy for asymptomatic bacteriuria or candiduria in advanced cancer patients transitioning to comfort measures Rupak Datta MD, PhD1,a
, Tianyun Wang MPH2,a, Mojun Zhu MD3, Louise Marie Dembry MD, MS, MBA1,2,
Ling Han MD, PhD4, Heather Allore PhD4,5, Vincent Quagliarello MD1 and Manisha Juthani-Mehta MD1,2 1Section of Infectious Diseases, Yale School of Medicine, New Haven, Connecticut, 2Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, Connecticut, 3Department of Hematology and Oncology, Mayo Clinic, Rochester, Minnesota, 4Section of Geriatrics, Yale School of Medicine, New Haven, Connecticut and 5Department of Biostatistics, Yale School of Public Health, New Haven, Connecticut
Abstract
Among 300 advanced cancer patients with potential urinary tract infection (UTI), 19 had symptomatic UTI. Among remaining patients (n=281), 21% had asymptomatic bacteriuria or candiduria, and 14% received inappropriate therapy for 279 antimicrobial days. Bacteriuria or candiduria predicted antimicrobial therapy. At 10,000 to <100,000 CFU/mL, the incidence rate ratio [IRR] was 16.9 (95% confidence interval [CI], 6.0–47.2), and at ≥100,000 CFU/mL, the IRR was 27.9 (95% CI, 10.9–71.2).
(Received 18 October 2018; accepted 18 January 2019)
More than 80% of advanced cancer patients are treated for infec- tion during terminal hospitalization.1 Among these infections, uri- nary tract infections (UTIs) predominate; reports suggest that 39%–42% involve potential UTI among advanced cancer patients receiving hospice care.2,3 Nevertheless, diagnosing UTI in this pop- ulation is challenging. Specifically, the identification of asympto- matic bacteriuria is complicated by immunosuppression and nonspecific clinical features. This is important because advanced cancer patients with potential UTI often receive antimicrobial therapy, 2,3 including inappropriate therapy for asymptomatic bacteriuria. The implications of inappropriate antimicrobial therapy for
asymptomatic bacteriuria are unique in advanced cancer patients and extend beyond antimicrobial overuse. Antimicrobial therapy in those receiving palliative care should be concordant with goals of care by promoting comfort and quality of life.4 However, anti- microbial therapy for asymptomatic bacteriuria conflicts with pal- liative goals of care if it provides no symptom relief and promotes adverse effects. Moreover, administering antimicrobials may cause pain and introduce additional infection risk. Evidence suggests antimicrobial stewardship interventions may
reduce urine culture ordering and inappropriate antimicrobial therapy for asymptomatic bacteriuria in catheterized patients.5 Less is known regarding the impact of stewardship interventions in noncatheterized advanced cancer patients.We sought to evaluate the association between asymptomatic bacteriuria or candiduria and
Author for correspondence: Rupak Datta, Email:
rupak.datta@yale.edu aAuthors of equal contribution.
PREVIOUS PRESENTATION: This work was presented in part in the session on
Antimicrobial Stewardship: Special Populations (presentation #248) at IDWeek 2018, on October 4, 2018, in San Francisco, California. Cite this article: Datta R, et al. (2019). Antimicrobial therapy for asymptomatic
bacteriuria or candiduria in advanced cancer patients transitioning to comfort measures. Infection Control&Hospital Epidemiology, 40: 470–472,
https://doi.org/10.1017/ice.2019.22
© 2019 by The Society for Healthcare Epidemiology of America. All rights reserved.
antimicrobial use in advanced cancer patients transitioning to comfort measures to inform stewardship interventions.
Methods
We conducted a cohort study of patients aged ≥65 years with advanced cancer who were transitioned to comfort measures dur- ing admission to Yale-New Haven Hospital, a 1,541-bed tertiary- care center in New Haven, Connecticut, between July 1, 2014, and November 31, 2016. Advanced cancer was defined as stage 3–4 solid tumors; stage 3–4 lymphomas; or acute, refractory, relapsed, or active liquid tumors requiring chemotherapy or targeted thera- pies. All advanced cancers were identified by International Classification of Diseases, Tenth Revision codes and were con- firmed on medical record review. We subsequently identified the subset of patients with potential UTI, defined as the collection of ≥1 urine culture during admission. The Yale Human Investigation Committee approved this study. For all advanced cancer patients with potential UTI, we col-
lected demographics, hospitalization information, urine catheter placement dates, urine culture results, and clinical features. Urine cultures were categorized as (1) no growth; (2) bacteriuria or candiduria 10,000 to <100,000 colony forming units per milli- liter (CFU/mL); or (3) bacteriuria or candiduria ≥100,000 CFU/ mL. Cultures with growth of ≤2 organisms were analyzed. Cultures with no growth, mixed flora (≥3 organisms), or growth <10,000CFU/mL were defined as no growth. UTI-associated clini- cal features included fever (>38°C), suprapubic tenderness, costo- vertebral angle pain or tenderness, urgency, frequency, or dysuria. Additional clinical features evaluated alternate criteria for UTI and included leukocytosis (>14,000 leukocytes/mm3), worsening mental status, urinary incontinence, and gross hematuria.6 Asymptomatic bacteriuria or candiduria was defined as urine
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