Reducing Catheter-Associated Urinary Tract Infections Across a Hospital System Through Urine Culture Stewardship.

Objective: To evaluate the effectiveness and safety of an evidence-based urine culture stewardship program in reducing hospital catheter-associated urinary tract infections (CAUTIs) and the rate of CAUTIs across a 3-hospital system. Patients and Methods: This is a prospective, 2-year quality improvement program conducted from October 1, 2018, to September 30, 2020. An evidence-based urine culture stewardship program was designed, which consisted of the following: criteria for allowing or restricting urine cultures from catheterized patients, a best practice advisory integrated into the ordering system of an electronic medical record, and a systematic provider education and feedback program to ensure compliance. The system-wide rates of CAUTIs (total CAUTIs/catheter days×1000), changes in intercepts, trends, mortality, length of stay, rates of device utilization, and rates of hospital-onset sepsis were compared for 3 years before and 2 years after the launch of the program. Results: Catheter-associated urinary tract infections progressively decreased after the initiation of the program (B=-0.21, P=.001). When the trends before and after the initiation of the program were compared, there were no statistically significant increases in the ratio of actual to predicted hospital length of stay, intensive care unit length of stay, system-wide mortality, and intensive care unit mortality. Although the rates of hospital-acquired sepsis remained consistent after the implementation of the stewardship program through the first quarter of 2020, the rates showed an increase in the second and third quarters of 2020. However, hospital-onset sepsis events associated with the diagnosis of a urinary tract infection did not increase after the intervention. Conclusion: Urine culture stewardship is a safe and effective way to reduce CAUTIs among patients in a large multihospital health care system. Patient safety indicators appeared unchanged after the implementation of the program, and ongoing follow-up will improve confidence in the long-term sustainability of this strategy.

Tonsillectomy does not improve bedwetting: results of a prospective controlled trial.

PURPOSE: Sleep disordered breathing caused by tonsillar hypertrophy has been implicated as a cause of primary and secondary nocturnal enuresis in children. We prospectively studied the preoperative and postoperative rates of nocturnal and daytime incontinence in a group of children with tonsillar hypertrophy undergoing tonsillectomy compared to a matched control group undergoing surgery unrelated to the airway or urinary tract. MATERIALS AND METHODS: A total of 326 toilet trained children 3 to 15 years old were included, with 257 in the tonsillectomy group and 69 in the control group. Severity of tonsillar hypertrophy was graded preoperatively on a scale of 1 to 4. A voiding questionnaire regarding number of bedwetting and daytime incontinence episodes per week, voids per day, bowel movements per week, secondary or primary enuresis and family history was completed by parents preoperatively, and at 3 and 6 months postoperatively. RESULTS: Preoperatively the respective rates of nocturnal enuresis and daytime incontinence were 33% and 17% in the tonsillectomy group (p=0.89), and 35% and 14% in the control group (p=0.3). The respective cure rates for bedwetting at 3 and 6 months postoperatively were 40% and 50% in the tonsillectomy group (p=0.60), and 35% and 48% in the control group (p=0.61). Similarly no difference was seen in improvement or cure of daytime incontinence at 3 and 6 months postoperatively. CONCLUSIONS: We found no association between tonsillar hypertrophy and urinary incontinence before or after tonsillectomy.

Pediatric urinary stone disease--does age matter?

PURPOSE: It has been proposed that younger children are less likely to pass renal calculi spontaneously, and that children younger than 10 years are more likely to have an identifiable metabolic abnormality and subsequently a higher risk of recurrence. We report our clinical outcomes in children with urinary calculi, specifically examining these factors. MATERIALS AND METHODS: We performed a retrospective review of all pediatric patients diagnosed with renal or ureteral calculi at our institution between 2000 and 2007. Of 150 patients evaluated and treated during this period 80 (86 stones) had sufficient followup data to be included. Patients were divided into 2 groups according to age, namely 10 years or younger and older than 10 years. There were 39 patients in the younger group and 41 patients in the older group. Stone size and location, successful passage or intervention, recurrence and 24-hour urine metabolic study results were recorded. RESULTS: Of the younger cohort stones were ureteral in 43% and renal in 57%. The opposite trend was seen in older patients, with 69% having ureteral and 31% having renal stones (p = 0.02). Mean stone size (greatest dimension) did not differ significantly between the older and younger groups (6.9 mm vs 5.5 mm, p = 0.17). Overall stone passage rate was 34% for younger and 29% for older patients (p = 0.65). No significant mean size differences in passed stones existed between the groups (3.2 mm vs 2.5 mm, p = 0.31). Overall younger vs older ureteral stone passage rate was 37% vs 41% (p = 0.58), and for renal stones it was 32% vs 0%. Stones recurred in 7 younger and 6 older patients. CONCLUSIONS: Younger children were more likely to present with renal stones, while older children had more ureteral stones. Overall children 10 years old or younger are as likely to pass stones as older children. Renal stones are more likely to be successfully managed expectantly in younger children. Metabolic abnormalities and stone recurrences are observed at similar rates between younger and older children.

Complete eversion of the urinary bladder: presentation, review, and algorithm for management.

BACKGROUND: Complete eversion of the urinary bladder is a rare problem that presents a serious management challenge. Currently no standard treatment recommendations exist for management. We describe our experience with bladder eversion and present an algorithm for treatment. CASE: An elderly, multiparous woman presented with complete bladder eversion after partial colpocleisis. Her bladder was reduced by a combined suprapubic and perineal approach with cystopexy to the anterior abdominal wall. CONCLUSION: Multiparous postmenopausal women appear to be at highest risk for complete bladder eversion. External transurethral reduction is sometimes successful, but most cases require laparotomy.

Protein oxidation as a novel biomarker of bladder decompensation.

OBJECTIVE: To measure the degree to which partial bladder outlet obstruction (PBOO) results in oxidative bladder damage, which subcellular components of the bladder are affected and whether these changes correlate with bladder function. MATERIALS AND METHODS: In all, 32 rabbits were divided into four groups. Each group underwent PBOO for 1, 2, 4, and 8 weeks, respectively. Bladder tissue from each group was homogenized and separated into subcellular fractions via differential centrifugation. The carbonyl content within the subcellular fractions, including the nuclear, mitochondrial, and microsomal pellets, was then quantified by dot blot analysis. RESULTS: Total bladder oxidation increased with duration of obstruction across all subcellular fractions. The largest increase in total oxidation occurred between 4 and 8 weeks. Protein oxidation density in the nuclear and microsomal fractions both showed increases at 2 weeks obstruction, decreases at 4 weeks, and then large increases at 8 weeks. The increase in protein oxidation density between 4 and 8 weeks obstruction was most pronounced in the microsomal fraction. CONCLUSIONS: Overall bladder protein oxidation increased with the duration of obstruction and increased at a greater rate during the transition to decompensation. Furthermore, the subcellular fraction that exhibited the most oxidation was the microsomal pellet. The amount of protein oxidation correlated with the functional changes in the bladder.

Cystogram may be unreliable in cases of gunshot wounds to the bladder: a case report.

INTRODUCTION: Gunshot wounds to the bladder are not uncommon; however it is unusual that a bullet come to rest within the urinary bladder. Properly performed plain film cystography is trusted as a highly sensitive tool for identifying significant bladder injuries due to both blunt and penetrating trauma. Several reports suggest that cystography may be less sensitive in cases of gunshot wounds to the bladder. METHODS: We report our recent experience with a gunshot wound to the bladder and review the use of cystography in the diagnosis of bladder injury in this setting. RESULTS: Anecdotal case reports suggest that cystography may fail to identify gunshot injuries to the bladder. No large studies have been performed to evaluate its utility in this unique trauma circumstance. CONCLUSIONS: Although reliable for the diagnosis of bladder perforation in most trauma settings, cystography may fail to diagnose a penetrating bladder injury due to a gunshot wound. High clinical suspicion based on bullet trajectory, history, and physical exam should guide the workup and treatment of such patients.

Community associated methicillin resistant Staphylococcus aureus causing Fournier's gangrene and genital infections.

PURPOSE: We identified an emerging infectious disease of the genitoperineum caused by community associated, methicillin resistant Staphylococcus aureus. MATERIALS AND METHODS: We report our experience with severe genital infections caused by community associated, methicillin resistant S. aureus occurring in 3 individuals who lacked any of the risk factors associated with traditional methicillin resistant S. aureus infection. Two cases were limited to scrotal abscesses that required only incision and drainage plus antimicrobial therapy. To our knowledge the third case represents the first and only reported case to date of Fournier's gangrene caused by community associated, methicillin resistant S. aureus. RESULTS: The prevalence of community associated, methicillin resistant S. aureus complicated skin and skin structure infections is increasing throughout the United States and other countries. Community associated, methicillin resistant S. aureus contains unique virulence factors but retains sensitivity to various nonbeta-lactam antibiotics. Historical risk factors associated with methicillin resistant S. aureus appear not to apply to infections associated with community associated, methicillin resistant S. aureus. Infections due to the latter cause have been identified in healthy individuals of all ages, races and ethnicities. Surgical and antimicrobial approaches to management are presented. CONCLUSIONS: Community associated, methicillin resistant S. aureus infections of the genitoperineum are likely to increase in incidence, necessitating heightened awareness on the part of the urologist.