J Am Pharm Assoc (2003). 2024 May-Jun;64(3):102043. doi: 10.1016/j.japh.2024.102043. Epub 2024 Feb 18.
Pyuria is nonspecific and may result in over-treatment of asymptomatic bacteriuria (ASB). The Infectious Diseases Society of America recommends against antibiotic treatment of ASB for most patients including those presenting with altered mental status (AMS). Close observation is recommended over treatment to avoid missing alternative causes of AMS and overuse of antibiotics resulting in adverse events and resistance.
The purpose of this study was to evaluate patient outcomes associated with antibiotic treatment of pyuria in patients presenting with AMS at hospital admission without specific urinary tract infection (UTI) symptoms. The primary objective was to compare 30-day readmission rates of patients with pyuria and AMS treated with antibiotics (AMS+Tx) versus those who were not treated (AMS-NoTx). Secondary outcomes included identifying risk factors for antibiotic treatment, comparing alternative diagnoses for AMS, and comparing safety outcomes.
This retrospective cohort study evaluated adult patients with AMS and pyuria (10 WBC/hpf) admitted between February 1, 2020 and October 1, 2021, in a 350-bed community teaching hospital. Patients with documented urinary symptoms were excluded. Additional exclusion criteria included admission to critical care, history of renal transplant, urological surgery, coinfections, pregnancy, and neutropenia.
Two-hundred patients were included (AMS+Tx, n = 162; AMS-NoTx, n=38). There was no difference in 30-day hospital readmission rate for AMS between groups (AMS+Tx 16.7% vs AMS-NoTx 23.7%, P = 0.311). An alternative diagnosis of AMS occurred more frequently when antibiotics were withheld (AMS+Tx 66% vs. AMS-NoTx 86.8%, P = 0.012). Urinalyses showing bacteria (odds ratio 2.52; 95% CI, 1.11-5.731) and positive urine culture (OR 3.36; 95% CI, 1.46-7.711) were associated with antibiotic prescribing.
Inappropriate antibiotic use is common among hospitalized patients presenting with AMS and pyuria; however, treatment of asymptomatic pyuria did not decrease rates of subsequent readmission for AMS or retreatment of symptomatic UTI. Patients who were monitored off antibiotics had higher rates of alternative AMS diagnosis.
脓尿不具特异性，可能导致无症状性菌尿（ASB）的过度治疗。美国传染病学会建议对大多数患者（包括出现精神状态改变（AMS）的患者）的 ASB 不进行抗生素治疗。建议密切观察而非治疗，以避免漏诊 AMS 的其他原因和抗生素的过度使用导致的不良反应和耐药性。
本研究旨在评估在入院时出现 AMS 且无特定尿路感染（UTI）症状的患者中，脓尿患者接受抗生素治疗的患者结局。主要目的是比较脓尿和 AMS 患者接受抗生素治疗（AMS+Tx）与未接受治疗（AMS-NoTx）的 30 天再入院率。次要结局包括确定抗生素治疗的危险因素，比较 AMS 的其他诊断，并比较安全性结局。
本回顾性队列研究评估了 2020 年 2 月 1 日至 2021 年 10 月 1 日期间在一家 350 床位的社区教学医院就诊的 AMS 合并脓尿（白细胞 10 个/高倍视野）的成年患者。排除有明确尿路症状的患者。其他排除标准包括入住重症监护病房、肾移植史、泌尿科手术、合并感染、妊娠和中性粒细胞减少症。
共纳入 200 例患者（AMS+Tx，n=162；AMS-NoTx，n=38）。两组 AMS 的 30 天院内再入院率无差异（AMS+Tx 16.7% vs AMS-NoTx 23.7%，P=0.311）。当不使用抗生素时，AMS 的其他诊断更为常见（AMS+Tx 66% vs. AMS-NoTx 86.8%，P=0.012）。尿液分析显示细菌（比值比 2.52；95%CI，1.11-5.731）和尿液培养阳性（OR 3.36；95%CI，1.46-7.711）与抗生素的使用相关。
在因 AMS 就诊且伴有脓尿的住院患者中，抗生素的使用并不恰当；然而，无症状性脓尿的治疗并未降低因 AMS 再次入院或治疗复发性 UTI 的发生率。未接受抗生素治疗的患者出现 AMS 其他诊断的几率更高。
