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Volume 154, No. 11

Published November 1, 2024

Review article: Biomedical intelligence

  1. Evangelia Liakoni, Samuel E. Christen, Neal L. Benowitz (Author)

    E-cigarettes, synthetic nicotine, heated-tobacco and smokeless nicotine delivery products: the nicotine landscape beyond combustible cigarettes

    Cigarette smoking remains an enormous public health problem causing millions of preventable deaths annually worldwide. Although safe and efficient smoking cessation pharmacotherapies such as nicotine replacement products and the medications varenicline and bupropion are available, long-term abstinence rates remain low and new approaches to help smokers successfully quit smoking are needed. In recent years, electronic nicotine delivery systems such as e-cigarettes and heated-tobacco products, and novel smokeless nicotine delivery products like nicotine pouches have gained widespread popularity. These products can deliver nicotine without combustion of tobacco and might thus present an alternative to the currently available smoking cessation methods if they prove able to help smokers quit smoking conventional cigarettes while decreasing their exposure to toxicants. In this narrative review, we provide a summary of the characteristics of these novel nicotine delivery products and the available data regarding their efficacy as smoking cessation tools and safety profile with a focus on the current situation in Switzerland.

  2. Beatriz Pozuelo Moyano, Kevin Swierkosz Lenart, Joëlle Rosselet Amoussou, Armin von Gunten, Jean-Pierre Schuster (Author)

    Prediction of electroconvulsive therapy response and remission in late-life depression: a review

    Electroconvulsive therapy is an effective and well-tolerated antidepressant treatment for the elderly population. The place of electroconvulsive therapy in the treatment sequence for depression in the elderly is currently not well established. This review aims to identify the factors that contribute to a positive response and remission in elderly patients with depression undergoing electroconvulsive therapy treatment.

    We searched five bibliographic databases (Medline ALL Ovid, Embase.com, APA PsycInfo Ovid, Cochrane Library Wiley and Web of Science Core Collection) for articles published between 1995 and June 2023. Of the 2149 articles screened, 19 were included in the review.

    No significant associations were found between remission and/or response and salivary cortisol, baseline hippocampal and white matter hyperintensities, total amyloid load or global cortical atrophy. The reviewed articles did not show a significant difference in remission between unilateral and bilateral electroconvulsive therapy treatment. Other interesting findings are that moderately elevated levels of CRP and S100B levels, lower retardation scores, poorer performance on the word reading task at baseline and longer post-ictal reorientation time may be associated with higher remission and/or response rates. Medial temporal atrophy can be associated with lower Montgomery-Åsberg Depression Rating Scale (MADRS) decrease after electroconvulsive therapy. Finally, elderly patients had higher rates of electroconvulsive therapy response; retardation and psychotic features may mediate this association.

    Incorporation of this data into clinical practice may facilitate a personalised approach to electroconvulsive therapy. However, research on this topic is scarce and there are few studies that focus specifically on older people.

  3. Natallia Laptseva, Dominik C. Benz, Rahel Schwotzer, Andreas J. Flammer (Author)

    Cardiac amyloidosis

    Cardiac amyloidosis is a disease characterised by the accumulation of amyloid protein in the heart tissue. There are several types of amyloidosis, but the most common types affecting the heart are ATTR amyloidosis (caused by transthyretin protein) and AL amyloidosis (caused by abnormal immunoglobulin light chains). Cardiac amyloidosis causes typical signs and symptoms of heart failure. Diagnosis involves a combination of imaging tests such as echocardiography and cardiac magnetic resonance imaging, as well as nuclear imaging scans and tissue biopsies to confirm the presence of amyloid deposits in the heart. Treatment of cardiac amyloidosis depends on the type and severity of the disease and includes medications to manage symptoms as well as treatments targeting the underlying cause of amyloidosis. Importantly, cardiac amyloidosis is a serious condition requiring specialised care from a multidisciplinary team including cardiologists and haematologists as well as other specialists familiar with the management of this rare disease. This is crucial, as early diagnosis and treatment are important for improving outcomes.

Original article

  1. Vanessa Gagliano, Gloria Salemme, Alessandro Ceschi, Angela Greco, Nicola Grignoli, Luca Clivio, Alessandro Merler, Vanessa Feyling Benitez, Jvan Gianini, Martina Zandonà , Luca Gabutti (Author)

    Antipsychotic, benzodiazepine and Z-drug prescriptions in a Swiss hospital network in the Choosing Wisely and COVID-19 eras: a longitudinal study

    AIMS OF THE STUDY: Physicians frequently prescribe antipsychotics off-label to treat, among others, insomnia and anxiety. The Swiss “smarter medicine – Choosing Wisely” campaign has tried to raise awareness about the risks and to limit benzodiazepine and Z-drug prescriptions. In the Italian-speaking part of Switzerland, our network of public hospitals joined the campaign with the aim of avoiding unnecessary benzodiazepine and Z-drug treatments, with prescription monitoring, benchmarking and educational contributions. Considering the risks of a possible shift towards the prescription of antipsychotics, and aware of the potential role of the COVID-19 pandemic, we decided to analyse the prescription trends of antipsychotics and benzodiazepines/Z-drugs before, during (2016–2017) and after the intervention.

    METHODS: For this longitudinal study, we reactivated a continuous monitoring of inpatient benzodiazepine/Z-drug and antipsychotics prescriptions/deprescriptions, paused in 2018 after the end of the internal Choosing Wisely campaign, based on routinely collected observational health data. We screened all demographic, administrative and prescription data of patients admitted to the internal medicine department of the four teaching hospitals (H1-H4) belonging to the EOC (Ente Ospedaliero Cantonale) network, from the fourth quarter of 2014 to the second quarter of 2023.

    RESULTS: We analysed 74,659 hospital stays (14,645 / 16,083 / 24,285 / 19,646 at hospitals H1 / H2 / H3 / H4 respectively). The mean (± SD) case mix (a metric that reflects the diversity, complexity and severity of the treated patients) and patient age were 1.08 ± 0.14 and 73 ± 2 years. 10.6% and 12.1% of patients received antipsychotics prior to admission and at discharge respectively (new prescriptions 3.3 ± 0.7%; deprescriptions 13.3 ± 5.2%). New prescriptions showed an upward trend, with +0.20% per year (p <0.001). Patients admitted with ongoing antipsychotics therapy increased 0.36% per year (p <0.001). New benzodiazepine/Z-drug prescriptions showed a 0.20% per year decrease (p = 0.01). Patients admitted with ongoing benzodiazepine/Z-drug therapy decreased 0.32% per year (p <0.001). New antipsychotics prescriptions showed differences between hospitals, with H3 above and H2 below the average.

    CONCLUSIONS: The increase in antipsychotics quantitatively matched the decrease in benzodiazepine/Z-drug prescribing, suggesting a shift from one to the other sedative therapy. The same trend was visible in the ongoing prescriptions at admission revealing a similar out-of-hospital approach. This suggests a change in sedative prescribing strategy rather than the choice of alternative, non-pharmacological approaches. Furthermore, the variation between similar services of different hospitals points out the consequences of local prescribing cultures and the importance of continuously monitoring and benchmarking medication prescriptions.

  2. Annora Mack, Sarah Rajkumar, Jacob Kofler, Kaspar Wyss (Author)

    Estimating the burden of disease attributable to non-assisted suicide in Switzerland from 2009 to 2021: a secondary data analysis

    CONTEXT AND GOAL: This research addresses the issue of suicide and attempted suicide, which have a significant impact on global premature mortality and disability. Particularly noteworthy is the prevalence among adolescents, in whom suicide ranks among the top four causes of death according to the World Health Organization (WHO). In Switzerland, suicide has remained the leading cause of death in individuals under 50 since 1990. At the same time, the burden of attempted suicides remains poorly understood. Although the legality of assisted suicide in Switzerland influences the overall suicide data, this analysis focuses solely on non-assisted suicides, as they are relevant for accurately assessing the burden of disease of suicide and attempted suicide. Amid challenges posed by limited reporting infrastructure, this analysis aims to contribute to the existing literature by investigating the cumulative impact of non-assisted suicide and attempted suicide on the population living in Switzerland.

    METHODOLOGY: Pre-existing data from 2009 to 2021 were collected and analysed, drawing from a variety of sources including official health records from the federal offices of statistics and public health, surveys and retrospective studies. From this data, years of life lost (YLLs), years lived with disability (YLDs) and disability-adjusted life-years (DALYs) were calculated in order to estimate the burden of disease. Sensitivity analyses were conducted to determine the robustness of the data and the effect of variables (suicide attempt incidence, sex distribution, disability weight, average duration) on the DALYs.

    RESULTS: The analysis of the data spanning from 2009 to 2021 revealed a decrease in suicide. The present study determined that, in 2021, 32,771 DALYs were attributable to non-assisted suicide and attempted suicide and 6.4% of all years of life lost (n = 30,516) were attributable to suicide, not including assisted suicide. Using a reference incidence of 33,000 attempted suicides per year in Switzerland, the morbidity associated with attempted suicides was 2255 YLDs (range: 552–6557 YLDs). Further analysis of the data highlighted a stark sex gap in the prevalence of non-assisted suicide: male suicides account for around 2% of all male deaths, whereas female suicides account for approximately 0.8% of all female deaths. Sensitivity analyses found that incidence and sex distribution of attempted suicide were the most impactful factors, while disability weights and average duration of disability had little impact on the variation in YLD estimates.

    CONCLUSION: In conclusion, this study provides a detailed analysis of the burden of non-assisted suicide and attempted suicide in Switzerland. With non-assisted suicide accounting for 6.4% of all years of life lost and 30% of deaths in people aged 20–24 in Switzerland in 2021, it emerges that suicide contributes significantly to the country’s overall disease burden, particularly in terms of years of life lost. The stark sex disparity in suicide rates further underscores the need for sex-sensitive approaches. These insights can help guide policy-making and the allocation of resources towards reducing the incidence and impact of suicide and attempted suicide, both in Switzerland and in broader international contexts where similar patterns prevail.

  3. Chloé Alberto, Noémie Wagner, Yves Fougère, Patrick M. Meyer Sauteur, Gioia Scherler, Karoline Aebbi-Popp, Marc Baumann, Nina Schöbi, Gaud Catho, Stéphane Emonet, Christian Polli, Lisa Kottanattu, Christian Kahlert, David Baud, Alix Coste, Begoña Martinez De Tejada, Klara M. Posfay Barbe, Laurence Toutous Trellu (Author)

    Syphilis in pregnant women and congenital syphilis from 2012 to 2021 in Switzerland: a multicentre, retrospective study

    BACKGROUND AND AIMS OF THE STUDY: Congenital syphilis is a rare complication of syphilis in pregnant women. Vertical transmission may occur at any time during pregnancy. The incidence of congenital syphilis has been increasing worldwide. Congenital syphilis has been a notifiable disease for many years in Switzerland but reporting does not include maternal features associated with syphilis in pregnancy or infantʼs subsequent development. We described syphilis cases among pregnant women screened over a 10-year period in Switzerland and subsequent cases of congenital syphilis, in order to identify maternal risk profiles and to optimise prevention. Second, we compared the characteristics of pregnant women screened early (1st trimester) vs late in pregnancy (2nd or 3rd trimester). Finally, we assessed the risk factors for premature birth among these women with syphilis.

    METHODS: A multicentre retrospective study conducted in Swiss hospitals from 2012 to 2021, including pregnant women who screened positive for syphilis (Treponema pallidum haemagglutination assay [TPHA] / T. pallidum particle agglutination assay [TPPA ] ≥1:80) and newborns exposed to T. pallidum in utero and/or congenitally infected and with a positive syphilis serology at birth. Data were collected from medical records.

    RESULTS: A total of 147 syphilis-positive pregnant women and 102 infants were included. A history of treated syphilis was known for 44% (65/147) of the mothers corresponding to a serological scar and the remaining 56% (82/147) were newly identified syphilis cases. Syphilis screening was done during the first trimester in 54%, second trimester in 29% and third trimester in 13% of cases. Two babies were diagnosed with congenital syphilis (1.96%). Several potential factors that could contribute to women’s risk of syphilis during pregnancy were identified such as a foreign origin (93% of mothers), lack of healthcare insurance (25%), no employment status (37%), drug use (5%), co-infection with other sexually transmitted infections (24%) and a late first antenatal consultation (42%). The number of pregnant women without insurance was higher in women diagnosed in the second or third trimester than in those diagnosed in the first trimester (odds ratio 0.41; 95% CI 0.19–0.89; p = 0.024). Syphilis diagnosed in the second or third trimester was associated with a late first antenatal consultation (odds ratio 77.82; 95% CI 9.81–617.21; p <0.001). A high rate of intrauterine growth retardation and of preterm birth was observed in newborns (18% versus 6% in Switzerland in 2022).

    CONCLUSION: Congenital syphilis remains rare in Switzerland. However, we found potential maternal factors associated with a positive syphilis serology during pregnancy, which can help to improve future prevention measures.

    The study protocol was registered on ClinicalTrials.gov (ID NCT05975502).

  4. Veronika W. Skrivankova, Leonie D. Schreck, Claudia Berlin, Radoslaw Panczak, Kaspar Staub, Marcel Zwahlen, Sven M. Schulzke, Matthias Egger, Claudia E. Kuehni (Author)

    Sociodemographic and regional differences in neonatal and infant mortality in Switzerland in 2011–2018: the Swiss National Cohort

    BACKGROUND AND AIMS: Despite a well-funded healthcare system with universal insurance coverage, Switzerland has one of the highest neonatal and infant mortality rates among high-income countries. Identifying avoidable risk factors targeted by evidence-based policies is a public health priority. We describe neonatal and infant mortality in Switzerland from 2011 to 2018 and explore associations with neonatal- and pregnancy-related variables, parental sociodemographic information, regional factors and socioeconomic position (SEP) using data from a long-term nationwide cohort study.

    METHODS: We included 680,077 live births, representing 99.3% of all infants born in Switzerland between January 2011 and December 2018. We deterministically linked the national live birth register with the mortality register and with census and survey data to create a longitudinal dataset of neonatal- and pregnancy-related variables; parental sociodemographic information, such as civil status, age, religion, education, nationality; regional factors, such as urbanity, language region; and the Swiss neighbourhood index of socioeconomic position (Swiss-SEP index). Information on maternal education was available for a random subset of 242,949 infants. We investigated associations with neonatal and infant mortality by fitting multivariable Poisson regression models with robust standard errors. Several sensitivity analyses assessed the robustness of our findings.

    RESULTS: Overall, neonatal mortality rates between 2011 and 2018 were 3.0 per 1000 live births, with regional variations: 3.2 in German-speaking, 2.4 in French-speaking and 2.1 in Italian-speaking Switzerland. For infant mortality, the rates were 3.7 per 1000 live births overall, and 3.9 in the German-speaking, 3.3 in the French-speaking and 2.9 in the Italian-speaking region. After adjusting for sex, maternal age, multiple birth and birth rank, neonatal mortality remained significantly associated with language region (adjusted rate ratio [aRR] 0.72, 95% confidence interval [CI]: 0.64–0.80 for the French-speaking region and aRR 0.66, 95% CI: 0.51–0.87 for the Italian-speaking region vs German-speaking region), with marital status (aRR 1.55, 95% CI: 1.40–1.71 for unmarried vs married), nationality (aRR 1.40, 95% CI: 1.21–1.62 for non-European Economic Area vs Swiss) and the Swiss-SEP index (aRR 1.17, 95% CI: 1.00–1.36 for lowest vs highest SEP quintile). In the subset, we showed a possible association of neonatal mortality with maternal education (aRR 1.24, 95% CI: 0.95–1.61 for compulsory vs tertiary education).

    CONCLUSION: We provide detailed evidence about the social patterning of neonatal and infant mortality in Switzerland and reveal important regional differences with about 30% lower risks in French- and Italian-speaking compared with German-speaking regions. Underlying causes for such regional differences, such as cultural, lifestyle or healthcare-related factors, warrant further exploration to inform and provide an evidence base for public health policies.

  5. Tugba Erdil, Klaus Steigmiller, John Ethan Rampa, Martin Christmann, Ulrike Held, Hitendu Dave (Author)

    Severity of native pulmonary annular hypoplasia and late outcomes of tetralogy of Fallot: retrospective cohort study

    OBJECTIVE: Pulmonary annular hypoplasia and valvar dysplasia are key morphological features affecting long-term outcomes of tetralogy of Fallot. This retrospective study aimed to analyse factors affecting contemporary long-term outcomes with a focus on pulmonary annular growth and function over time.

    METHODS: 131 consecutive isolated tetralogy of Fallot repairs performed between 2004 and 2014 at University Children’s Hospital Zurich were included. Median age and weight at the time of repair were 4.8 (interquartile range [IQR] 3.2–6.3) months and 6.1 (IQR 5.1–7) kg, respectively. Based on the severity of native pulmonary annular hypoplasia, the cohort was divided into group 1 (preoperative pulmonary annular Z score < –4; n = 20), group 2 (Z score –2 to –4; n = 56) and group 3 (Z score > –2; n = 54). A transannular patch was used in 88/131 (67.2%) patients: 80%, 67.9% and 61.1% in groups 1, 2 and 3, respectively. The primary outcome was defined as right ventricular outflow tract (RVOT) reoperation or pulmonary valve replacement. Secondary outcome was composite pulmonary valve dysfunction defined as peak gradient >40 mm Hg or severe pulmonary regurgitation at follow-up. A multiple Cox regression model was used to quantify the association of age at tetralogy of Fallot repair, preoperative pulmonary annular Z score and RVOT approach with primary and secondary outcome. Follow-up was 98.5% complete, with a median follow-up duration of 9.6 (95% confidence interval [CI] 9–10.4) years.

    RESULTS: All patients were alive at last follow-up resulting in 100% survival. 20/131 patients underwent pulmonary valve replacement (14 surgical and 6 catheter interventional) while 5/131 underwent RVOT reoperations other than valve replacement. The Kaplan-Meier 10-year freedom from primary outcome was 85% (95% CI 78–92%); 69% (46–100%), 91% (82–100%) and 84% (74–95%) for groups 1, 2 and 3, respectively (log rank p = 0.16). Composite dysfunction at follow-up was observed in 29.8% (overall): 45%, 28.6% and 25.9% for groups 1, 2 and 3, respectively (p = 0.12). The multiple Cox regression analysis for primary outcome indicated that the use of a transannular patch results in a Hazard Ratio (HR) of 3.3 (95% CI 0.7–14.7, p = 0.13). Additionally, the presence of composite dysfunction at discharge results in a HR of 2.1 (95% CI 0.8–5.4, p = 0.1). Age (in months) with a HR of 0.8 (95% CI 0.6–1, p = 0.06) and group 2 with a HR of 0.4 (95% CI 0.14–1.2, p = 0.11) showed a trend to being protective for the primary outcome. However, the 95% CI of all estimates included the HR of 1.

    CONCLUSIONS: Transannular patch use and composite dysfunction at discharge, although not statistically significant at 5% level, may be associated with pulmonary valve replacement and RVOT reoperation. Avoiding the use of a transannular patch or using reconstructive techniques to achieve a better composite dysfunction at discharge could reduce the primary outcome. Large multicentre studies are needed to demonstrate more precisely the impact of pulmonary annulus Z scores on outcome.

  6. Maria Breiding, Maarja Soomann, Michèle Roth, Johannes Trück, Felicitas Bellutti Enders (Author)

    Safety of oral immunotherapy for cashew nut and peanut allergy in children – a retrospective single-centre study

    AIM OF THE STUDY: Oral immunotherapy (OIT) is increasingly used for the treatment of childhood food allergies, with limited data available on cashew nut OIT. This real-life study investigated the safety and feasibility of cashew nut OIT, comparing it with peanut OIT, with a focus on the up-dosing process.

    METHODS: We analysed cashew nut (n = 24) and peanut (n = 38) OIT cases with treatment initiated between 2018 and 2022 at the University Childrenʼs Hospital Basel. All patients who commenced therapy within this time frame were enrolled without prior selection. Two different starting protocols were used. Within the up-dosing protocol, the nut intake was incrementally increased by 20–30% every 2 weeks until reaching a maintenance dose of 1 g of nut protein. After consuming the maintenance dose regularly for 18–24 months, a second oral food challenge was performed. Patients who passed this challenge were considered desensitised. The safety of the therapy was evaluated based on the severity of adverse reactions during the up-dosing phase. Symptom severity was evaluated using the validated ordinal food allergy severity scale (o-FASS-5).

    RESULTS: Over the study period, 33% of cashew nut-allergic and 63% of peanut-allergic patients experienced mild to moderate allergic reactions. Severe allergic reactions occurred in five peanut-allergic children with high baseline allergen-specific IgE levels. Six patients with peanut, and none with cashew nut OIT, discontinued the therapy due to adverse reactions. The mean duration to reach the maintenance phase was longer for children with asthma or another food allergy. Among children who already underwent the second oral food challenge, desensitisation was achieved in 91% (11 out of 12) of cashew nut- and 73% (11 out of 15) of peanut-allergic patients.

    CONCLUSION: Cashew nut OIT had a low severity of adverse reactions and was generally well-tolerated. However, patient characteristics influenced side effect risk and treatment duration, emphasising the need for individualised OIT strategies.

  7. Stefania Di Gangi, Roman Brenner, Thomas Grischott, Jakob Martin Burgstaller, Oliver Senn, Thomas Rosemann, Stefan Markun (Author)

    Blood pressure control and antihypertensive treatment in Swiss general practice: a cross-sectional study using routine data

    AIMS OF THE STUDY: Arterial hypertension is a major global health risk. Global surveys indicate that only half of patients with arterial hypertension receive pharmacotherapy, and only a quarter achieve the primary blood pressure target recommended by guidelines. This study aimed to evaluate the achievement of the primary blood pressure target in Swiss general practice, provide insights into arterial hypertension treatment, and identify factors associated with achieving this goal.

    METHODS: This cross-sectional study utilised data from a large Swiss primary care database. Patients with arterial hypertension, aged ≥18 years, who underwent blood pressure monitoring in 2021 were included. The primary observation was blood pressure control, defined as the achievement of the primary blood pressure target of systolic blood pressure <140 mm Hg and diastolic blood pressure <90 mm Hg. Demographic data from physicians and patients, blood pressure measurements, comorbidities, cardiovascular risk factors, and pharmacotherapy were collected, and arterial hypertension stages were calculated. Unadjusted and multivariable-adjusted mixed logistic regression models were used to identify factors associated with blood pressure control.

    RESULTS: A total of 49,290 patients were included, of whom 23,933 (48.6%) were female. The median patient age was 71 years (interquartile range 61–80). Blood pressure control was observed in 23,022 patients (46.7%), and 36,692 patients (74.4%) had an antihypertensive pharmacotherapy prescription. In multivariable analysis, blood pressure control was positively associated with arterial hypertension stage, antihypertensive pharmacotherapy, the intensity of blood pressure monitoring, and the number of blood pressure-increasing drugs, but negatively associated with a long-standing arterial hypertension, female sex, and old age.

    CONCLUSIONS: While general practitioners appear to consider arterial hypertension stages in their treatment strategies, there is still room for improvement in arterial hypertension care by prescribing pharmacotherapy, especially in patients with long-standing arterial hypertension, female sex and old age.

  8. Iris Zünti, Emilio Arbelaez, Sarah Tschudin-Sutter, Andreas Zeller, Florian S. Halbeisen, Hans-Helge Seifert, Kathrin Bausch (Author)

    Exploring the real-world management of catheter-associated urinary tract infections by Swiss general practitioners and urologists: insights from an online survey

    AIM: To assess and compare the real-world management of catheters and catheter-associated urinary tract infections (CAUTI) among Swiss general practitioners and urologists, encompassing diagnosis, treatment and prophylaxis.

    METHODS: An anonymised online questionnaire was distributed among Swiss general practitioners and urologists between January and October 2023 via the networks of Sentinella and the Swiss Association of Urology. The questionnaire consisted of questions on catheter management, including diagnosis, treatment and prophylaxis of CAUTI. Analysis was performed by discipline. Fisher’s exact test was applied for comparisons (statistical significance with p <0.05).

    RESULTS: Out of 175 participating physicians, the majority were involved in catheter management. Urologists exhibited significantly higher levels of competence as compared to general practitioners (67.1% vs 20.9%). Although no significant differences were observed regarding diagnostic approaches between disciplines, unrecommended diagnostic methods were frequently applied. general practitioners reported that they treated non-febrile CAUTI for longer durations, while urologists indicated that they treated febrile CAUTI longer. Additionally, the use of fluoroquinolones was more prevalent among general practitioners compared to urologists, while prophylactic measures were more frequently applied by urologists.

    CONCLUSIONS: Catheter and CAUTI management entail significant uncertainty for general practitioners. CAUTI management varied notably between general practitioners and urologists in terms of treatment and prophylaxis. The use of non-recommended diagnostic approaches and drugs was common. This trend, along with inappropriate diagnostic methods and prophylaxis, may increase antimicrobial resistance and CAUTI morbidity. The study emphasises the necessity for diagnostic and antimicrobial stewardship interventions, and proper training in CAUTI management for general practitioners and urologists.

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