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The potential impact of biomarker-guided triage decisions for patients with urinary tract infections

  • Clinical and Epidemiological Study
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Abstract

Objectives

Current guidelines provide limited evidence as to which patients with urinary tract infection (UTI) require hospitalisation. We evaluated the currently used triage routine and tested whether a set of criteria including biomarkers like proadrenomedullin (proADM) and urea have the potential to improve triage decisions.

Methods

Consecutive adults with UTI presenting to our emergency department (ED) were recruited and followed for 30 days. We defined three virtual triage algorithms, which included either guideline-based clinical criteria, optimised admission proADM or urea levels in addition to a set of clinical criteria. We compared actual treatment sites and observed adverse events based on the physician judgment with the proportion of patients assigned to treatment sites according to the three virtual algorithms. Adverse outcome was defined as transfer to the intensive care unit (ICU), death, recurrence of UTI or rehospitalisation for any reason.

Results

We recruited 127 patients (age 61.8 ± 20.8 years; 73.2 % females) and analysed the data of 123 patients with a final diagnosis of UTI. Of these 123 patients, 27 (22.0 %) were treated as outpatients. Virtual triage based only on clinical signs would have treated only 22 (17.9 %) patients as outpatients, with higher proportions of outpatients equally in both biomarker groups (29.3 %; p = 0.02). There were no significant differences in adverse events between outpatients according to the clinical (4.5 %), proADM (2.8 %) or urea groups (2.8 %). The mean length of stay was 6.6 days, including 2.2 days after reaching medical stability.

Conclusions

Adding biomarkers to clinical criteria has the potential to improve risk-based triage without impairing safety. Current rates of admission and length of stay could be shortened in patients with UTI.

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References

  1. Nicolle LE. Epidemiology of urinary tract infections. Infect Med. 2001;18:153–62.

    Google Scholar 

  2. Curns AT, Holman RC, Sejvar JJ, Owings MF, Schonberger LB. Infectious disease hospitalizations among older adults in the United States from 1990 through 2002. Arch Intern Med. 2005;165:2514–20.

    Article  PubMed  Google Scholar 

  3. Blondeau JM. Current issues in the management of urinary tract infections: extended-release ciprofloxacin as a novel treatment option. Drugs. 2004;64:611–28.

    Article  PubMed  CAS  Google Scholar 

  4. Covinsky KE, Pierluissi E, Johnston CB. Hospitalization-associated disability: “She was probably able to ambulate, but I’m not sure”. JAMA. 2011;306:1782–93.

    Article  PubMed  CAS  Google Scholar 

  5. Chalmers JD, Al-Khairalla M, Short PM, Fardon TC, Winter JH. Proposed changes to management of lower respiratory tract infections in response to the Clostridium difficile epidemic. J Antimicrob Chemother. 2010;65:608–18.

    Article  PubMed  CAS  Google Scholar 

  6. Aliyu ZY, Aliyu MH, McCormick K. Determinants for hospitalization in “low-risk” community acquired pneumonia. BMC Infect Dis. 2003;3:11.

    Article  PubMed  Google Scholar 

  7. Labarere J, Stone RA, Scott Obrosky D, et al. Factors associated with the hospitalization of low-risk patients with community-acquired pneumonia in a cluster-randomized trial. J Gen Intern Med. 2006;21:745–52.

    Article  PubMed  Google Scholar 

  8. van Nieuwkoop C, van’t Wout JW, Spelt IC, et al. Prospective cohort study of acute pyelonephritis in adults: safety of triage towards home based oral antimicrobial treatment. J Infect. 2010;60:114–21.

    Article  PubMed  Google Scholar 

  9. Warren JW, Abrutyn E, Hebel JR, Johnson JR, Schaeffer AJ, Stamm WE. Guidelines for antimicrobial treatment of uncomplicated acute bacterial cystitis and acute pyelonephritis in women. Infectious Diseases Society of America (IDSA). Clin Infect Dis. 1999;29:745–58.

    Article  PubMed  CAS  Google Scholar 

  10. Bass PF 3rd, Jarvis JA, Mitchell CK. Urinary tract infections. Prim Care. 2003;30:41–61, v–vi.

    Article  PubMed  Google Scholar 

  11. Hooton TM. The current management strategies for community-acquired urinary tract infection. Infect Dis Clin North Am. 2003;17:303–32.

    Article  PubMed  Google Scholar 

  12. Ramakrishnan K, Scheid DC. Diagnosis and management of acute pyelonephritis in adults. Am Fam Physician. 2005;71:933–42.

    PubMed  Google Scholar 

  13. Kim K, Lee CC, Rhee JE, et al. The effects of an institutional care map on the admission rates and medical costs in women with acute pyelonephritis. Acad Emerg Med. 2008;15:319–23.

    Article  PubMed  Google Scholar 

  14. Hooton TM. Clinical manifestations; diagnosis; and treatment of acute pyelonephritis. In: Calderwood SB, Baron EL, editors. UpToDate. Retrieved from http://www.uptodate.com/home/index.html.

  15. Grabe M, Bjerklund-Johansen TE, Botto H, Çek M, Naber KG, Tenke P, Wagenlehner F. Guidelines on urological infections. European Association of Urology (EAU) guidelines. Edition presented at the 25th Anniversary EAU Congress, Barcelona, Spain, April 2010.

  16. Nanda N, Juthani-Mehta M. Novel biomarkers for the diagnosis of urinary tract infection—a systematic review. Biomark Insights. 2009;4:111–21.

    PubMed  CAS  Google Scholar 

  17. Schuetz P, Albrich W, Mueller B. Procalcitonin for diagnosis of infection and guide to antibiotic decisions: past, present and future. BMC Med. 2011;9:107.

    Article  PubMed  CAS  Google Scholar 

  18. Chalupa P, Beran O, Herwald H, Kaspříková N, Holub M. Evaluation of potential biomarkers for the discrimination of bacterial and viral infections. Infection. 2011;39:411–7.

    Article  PubMed  CAS  Google Scholar 

  19. Lipinska-Gediga M, Mierzchala M, Durek G. Pro-atrial natriuretic peptide (pro-ANP) level in patients with severe sepsis and septic shock: prognostic and diagnostic significance. Infection. 2012;40:303–9.

    Article  PubMed  CAS  Google Scholar 

  20. Christ-Crain M, Morgenthaler NG, Struck J, Harbarth S, Bergmann A, Müller B. Mid-regional pro-adrenomedullin as a prognostic marker in sepsis: an observational study. Crit Care. 2005;9:R816–24.

    Article  PubMed  Google Scholar 

  21. Schuetz P, Wolbers M, Christ-Crain M, et al. Prohormones for prediction of adverse medical outcome in community-acquired pneumonia and lower respiratory tract infections. Crit Care. 2010;14:R106.

    Article  PubMed  Google Scholar 

  22. Albrich WC, Dusemund F, Rüegger K, et al. Enhancement of CURB65 score with proadrenomedullin (CURB65-A) for outcome prediction in lower respiratory tract infections: derivation of a clinical algorithm. BMC Infect Dis. 2011;11:112.

    Article  PubMed  Google Scholar 

  23. Albrich WC, Rüegger K, Dusemund F, et al. Optimised patient transfer using an innovative multidisciplinary assessment in Kanton Aargau (OPTIMA I): an observational survey in lower respiratory tract infections. Swiss Med Wkly. 2011;141:w13237.

    PubMed  CAS  Google Scholar 

  24. Morgenthaler NG, Struck J, Alonso C, Bergmann A. Measurement of midregional proadrenomedullin in plasma with an immunoluminometric assay. Clin Chem. 2005;51:1823–9.

    Article  PubMed  CAS  Google Scholar 

  25. Regeniter A, Haenni V, Risch L, et al. Urine analysis performed by flow cytometry: reference range determination and comparison to morphological findings, dipstick chemistry and bacterial culture results—a multicenter study. Clin Nephrol. 2001;55:384–92.

    PubMed  CAS  Google Scholar 

  26. Kouri T, Fogazzi G, Gant V, Hallander H, Hofmann W, Guder WG. European urinalysis guidelines. Scand J Clin Lab Invest Suppl. 2000;60:1–96.

    Article  Google Scholar 

  27. Bent S, Nallamothu BK, Simel DL, Fihn SD, Saint S. Does this woman have an acute uncomplicated urinary tract infection? JAMA. 2002;287:2701–10.

    Article  PubMed  Google Scholar 

  28. Fairley KF, Carson NE, Gutch RC, et al. Site of infection in acute urinary-tract infection in general practice. Lancet. 1971;2:615–8.

    Article  PubMed  CAS  Google Scholar 

  29. Scholes D, Hooton TM, Roberts PL, Gupta K, Stapleton AE, Stamm WE. Risk factors associated with acute pyelonephritis in healthy women. Ann Intern Med. 2005;142:20–7.

    Article  PubMed  Google Scholar 

  30. Claessens YE, Schmidt J, Batard E, et al. Can C-reactive protein, procalcitonin and mid-regional pro-atrial natriuretic peptide measurements guide choice of in-patient or out-patient care in acute pyelonephritis? Biomarkers In Sepsis (BIS) multicentre study. Clin Microbiol Infect. 2010;16:753–60. doi:10.1111/j.1469-0691.2009.02955.x.

    Google Scholar 

  31. Elkharrat D, Chastang C, Boudiaf M, Le Corre A, Raskine L, Caulin C. Relevance in the emergency department of a decisional algorithm for outpatient care of women with acute pyelonephritis. Eur J Emerg Med. 1999;6:15–20.

    PubMed  CAS  Google Scholar 

  32. Roberts DC, McKay MP, Shaffer A. Increasing rates of emergency department visits for elderly patients in the United States, 1993 to 2003. Ann Emerg Med. 2008;51:769–74.

    Article  PubMed  Google Scholar 

  33. Businger AP, Kaderli R, Burghardt LR, Osinga R, Liesch M, Furrer M. Demographic changes and their implications in a nonacademic emergency department in Switzerland: an 11-year trend analysis (2000–2010) of 104,510 patients. ISRN Emerg Med. 2012:Article ID 865861;2012. doi:10.5402/2012/865861.

  34. Foxman B, Klemstine KL, Brown PD. Acute pyelonephritis in US hospitals in 1997: hospitalization and in-hospital mortality. Ann Epidemiol. 2003;13:144–50.

    Article  PubMed  Google Scholar 

  35. Baehni C, Meier S, Spreiter P, et al. Which patients with lower respiratory tract infections need inpatient treatment? Perceptions of physicians, nurses, patients and relatives. BMC Pulm Med. 2010;10:12.

    Article  PubMed  Google Scholar 

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Acknowledgments

We are grateful to all the physicians, nurses, social workers and patients who participated in this study. Especially, we thank Petra Tobias and the staff of the emergency room, Susanne Schirlo and the staff of the medical clinic, Renate Hunziker, Martha Kaeslin and the central laboratory of the Kantonsspital Aarau for their very helpful assistance and technical support.

Conflict of interest

Werner Albrich and Beat Mueller received support from BRAHMS Thermo Fisher and from bioMérieux to attend meetings and fulfilled speaking engagements and served as consultants for BRAHMS Thermo Fisher. Beat Müller received research support from BRAHMS Thermo Fisher. All other authors report no conflict of interest.

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Authors and Affiliations

  1. Medical University Department of the University of Basel, Kantonsspital Aarau, Tellstrasse, 5001, Aarau, Switzerland

    A. Litke, B. Mueller & W. C. Albrich

  2. Department of Clinical Nursing Science, Kantonsspital Aarau, Aarau, Switzerland

    R. Bossart, K. Regez, U. Schild, M. Guglielmetti, A. Conca, P. Schäfer & B. Reutlinger

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  1. A. Litke
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Correspondence to A. Litke.

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Litke, A., Bossart, R., Regez, K. et al. The potential impact of biomarker-guided triage decisions for patients with urinary tract infections. Infection 41, 799–809 (2013). https://doi.org/10.1007/s15010-013-0423-1

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  • DOI: https://doi.org/10.1007/s15010-013-0423-1

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