Diagnosis Of Cystitis Research Articles

Prostate cancer survivors with symptoms of radiation cystitis have elevated fibrotic and vascular proteins in urine.

Radiation for pelvic cancers can result in severe bladder damage and radiation cystitis (RC), which is characterized by chronic inflammation, fibrosis, and vascular damage. RC development is poorly understood because bladder biopsies are difficult to obtain. The goal of this study is to gain understanding of molecular changes that drive radiation-induced cystitis in cancer survivors using urine samples from prostate cancer survivors with history of radiation therapy. 94 urine samples were collected from prostate cancer survivors with (n = 85) and without (n = 9) history of radiation therapy. 15 patients with radiation history were officially diagnosed with radiation cystitis. Levels of 47 different proteins were measured using Multiplex Luminex. Comparisons were made between non-irradiated and irradiated samples, and within irradiated samples based on radiation cystitis diagnosis, symptom scores or hematuria. Statistical analysis was performed using Welch's t-test. In prostate cancer survivors with history of radiation therapy, elevated levels of PAI 1, TIMP1, TIMP2, HGF and VEGF-A were detected in patients that received a radiation cystitis diagnosis. These proteins were also increased in patients suffering from hematuria or high symptom scores. No inflammatory proteins were detected in the urine, except in patients with gross hematuria and end stage radiation cystitis. Active fibrosis and vascular distress is detectable in the urine through elevated levels of associated proteins. Inflammation is only detected in urine of patients with end-stage radiation cystitis disease. These results suggest that fibrosis and vascular damage drive the development of radiation cystitis and could lead to the development of more targeted treatments.

Anal Atresia and Structural Malformations of the Perineum and Anus in a Mare

Background: Anal atresia is a congenital defect and is related to the flaw of an opening in the membrane that separates the endoderm of the posterior intestine from the ectodermic anal membrane. This anomaly can cause debilitating disease, death, or abnormal development of the animal. Clinical presentation of urethrorectal fistula in domestic animals differs between males and females, as in the former there is passage of the urine through the anus, whereas in females there is elimination of the feces through the vulva. The absence of description of this disease in horses stimulated describing a case of surgical resolution of anal atresia, rectal bulb agenesis, and pneumovagina of an adult mare.Case: Mare with a history of defecating through the vagina. In the anamnesis, it was determined that the owner noticed the problem after observing the animal during a walk. Clinical examination verified absence of the anus with stool evacuation through the vagina, pneumovagina, and signs of cystitis, as the animal frequently urinated small volumes. Complementary laboratory tests of blood and urine were carried out for the diagnosis of cystitis, serum biochemistry, hemogram, and urinalysis being evaluated. The operation was scheduled for eight days after clinical tests and sodium ceftiofur was prescribed, at a dose of 4.4 mg/kg, administered intramuscularly for seven days. On the date chosen for surgical intervention, the animal was fasted for the previous 12 h; procedures began with the containment of the animal in a stock, followed by pre-anesthesia with detomidine, at a dose of 20 µg/kg, administered intravenously in solution at 1%. Anesthesia was a low peridural with 2% lidocaine at a total dose of 15 mL, to be able to work in the quadruped position. After containment of the tail and taking antiseptic and aseptic care, sutures were made in the skin and vaginal mucous, as it exhibited a solution of continuity. In the mucous, suture consisted of separate simple stitches made with perforation needle and 2-0 polyglactin 910 suture, while in the skin Wolff stitches were applied using a blade needle and 2-0 nylon suture. Then, a circular incision was made in the skin in the anus region to remove local skin; this revealed the rectum which, being it far from the required location, was pulled to the new opening. The rectum was fixed to the skin by suture: four simple stiches, with a perforation needle and zero nylon suture, to serve as repairs, followed by simple stitches between the repairs, with the same type of suture. Regarding the pneumovagina, reconstruction of the perineum and application of modified Calisck surgical technique were performed to correct the vulva defect. In the post-operative phase, 4.4 mg/kg of sodium ceftiofur was administered intramuscularly for seven days, and Flunixin Meglumine, at a dose of 1.1 mg/ml for every 50 kg of body weight, was administered intravenously for four days. Furthermore, rectal enemas (3 L of warm aqueous solution associated with glycerin) were administered every eight hours for 14 consecutive days, and the wound was cleaned with 2% chlorhexidine degerming solution. The skin sutures were removed after 15 days and the animal was discharged.Discussion: Alteration of the digestive tract in horses presents nuances in genetic dependence, embryology, and congenital defects, among others. Regarding the possibility of surgical correction, it is necessary to observe the characteristics of the lesion, the handling to which the animal is subjected, care of the surgical wound, and physical conditions where surgical procedures are carried out. The results obtained with this intervention and pre-, trans-, and post-operative care were effective in reestablishing the patient.

Antibiotic Prescribing in New York State Medicare Part B Beneficiaries Diagnosed With Cystitis Between 2016 and 2017.

BackgroundStatewide tracking and reporting is an outpatient antimicrobial stewardship tool that may be useful for many stakeholders. However, to date, these evaluations have been limited. This study aimed to track and report outpatient antibiotic prescribing in Medicare Part B enrollees diagnosed with cystitis in the outpatient setting.MethodsThis was a retrospective, cohort study of Medicare Part B enrollees in New York State. Inclusion criteria include outpatient visit in 2016 or 2017, cystitis diagnosis code, and oral antibiotic prescription ≤3 days after diagnosis of cystitis. Antibiotics were categorized as first-line, oral β-lactams, fluoroquinolones, or other per Infectious Diseases Society of America acute uncomplicated cystitis guidelines. Data were stratified by sex. Annual prescriptions proportions were compared using χ 2 test or Fisher’s exact test as appropriate.ResultsA total of 50 658 prescriptions were included. For females’ prescriptions, first line increased (41.5% vs 43.8%, P < .0001), oral β-lactams increased (17.8% vs 20.5%, P < .0001), fluoroquinolones decreased (34.1% vs 29.1%, P < .0001), and other increased (6.5% vs 6.6%, P = .76) in 2017. For males’ prescriptions, first line increased (25.2% vs 26.7%, P = .11), oral β-lactams increased (23.1% vs 26.2%, P = .0003), fluoroquinolones decreased (44.0% vs 39.3%, P < .0001), and other remained unchanged (7.8% vs 7.8%, P = .92) in 2017.ConclusionsGuideline concordant therapy prescribing for cystitis increased among Medicare Part B beneficiaries in New York State between 2016 and 2017. However, there was still a high prevalence of fluoroquinolone prescribing. These data highlight the need for additional outpatient antimicrobial stewardship efforts in New York State.

1105. Statewide, Retrospective, Cohort Study of Medicare Part B Quinolone Prescribing for Cystitis in 2016–2017

BackgroundQuinolones (FQ) are no longer recommended as first-line therapy for cystitis. In 2016, the FDA released a safety communication advising FQ restriction in the treatment of uncomplicated urinary tract infection unless no other options are available. However, little is known about the frequency of FQ (FFQ) prescribing in older adults (OA) receiving antibiotics for cystitis in New York State (NYS). This study compared the FFQ prescribing in OA receiving antibiotics with a diagnosis of cystitis in NYS between 2016 and 2017.MethodsRetrospective, cohort study of (NYS) Part B Medicare fee-for-service beneficiaries in 2016 and 2017 with diagnosis codes for cystitis. All antibiotics prescribed ≤ 3 days after visit were analyzed. FQ were defined as ciprofloxacin, gemifloxacin, levofloxacin, moxifloxacin, norfloxacin, ofloxacin. County-wide data were aggregated into regional data per NYS Department of Health Population Health Improvement Program categories, but New York City counties were not grouped. FFQ was analyzed at the state and regional level and was defined as the total # of FQ prescriptions / total # of antibiotic prescriptions with the diagnostic code for cystitis. χ 2 test and Risk Ratios (RR = 2017 FFQ/2016 FFQ) were used to compare 2016 and 2017 FFQs for the state and for each region using SAS v 9.3 (α = 0.05).Results50,658 antibiotic prescriptions were written for Medicare beneficiaries diagnosed with cystitis in NYS. The statewide FFQ decreased by 14% from 35.9% in 2016 to 31.0% in 2017 (RR: 0.86 [95% CI: 0.84 – 0.88], P < 0.001). FFQ decreased significantly in 11 of 15 regions (P < 0.05, Figures 1 and 2). The median (IQR) FFQ RR for the regions was 0.83 (0.81, 0.87) (Figure 3). The regions (RR [95% CI]) with the largest decrease were Bronx (0.78 [0.67,0.91]), Finger Lakes (0.80 [0.71,0.89]) and Central New York (0.81 [0.72,0.91]). Limited or no changes were observed in Brooklyn (1.01 [0.94, 1.09]), Queens (0.97 [0.88, 1.06]) and Staten Island (0.95 [0.79, 1.13]).ConclusionOn a statewide level, there were significant decreases in FFQ for cystitis in older adults in 2017 compared with 2016. Nevertheless, up to a third of cystitis prescription were for FQ. Future studies should evaluate the appropriateness of FQ for cystitis in OA. Disclosures All authors: No reported disclosures.

1449. Antibiotic Choice, Duration, and Outcome in Community-Acquired Urinary Tract Infections (UTI) in Male Patients

BackgroundIt is common medical practice for all urinary tract infections (UTIs) in males to be diagnosed as “complicated” UTIs. Current guidelines recommend 7 to 14 days of antibiotics for complicated UTIs. Longer duration of antibiotics potentially exposes a patient to harm without sufficient evidence for benefit. This research will attempt to determine the optimal antibiotic and duration of treatment for males diagnosed with a UTI.MethodsThis study is a retrospective cohort study that utilized the electronic health record for Kaiser Permanente Southern California to search for male patients with a diagnosis of cystitis or UTI in the outpatient setting from 2011 to 2016. Only patients with confirmed bacteriuria >100,000 CFU/mL of a gram-negative organism were included. Exclusion criteria included Foley catheterization, intermittent self-catheterization, prostatitis and Pseudomonas infection. There were 10,662 patients in our database who fit these criteria, but only 134 patients were reviewed for preliminary analysis for this abstract. Outcomes included recurrence of UTI within 30 days of finishing treatmentResultsA total of 134 patients were included. Most patients were prescribed Ciprofloxacin (69%) or Cephalexin (19%). The prescription duration was >8 days for 52%, 7–8 days for 34% and <7 days for 14% of all the patients. There was a statistically significant difference in recurrence by antibiotic duration (Figure 1). The odds of recurrence were 3.9 times higher for people with <7 days prescription compared with those with > 8 days (95% CI, 1.28–11.89, P = .017) (Table 1). The odds of recurrence were 1.5 times higher for those with a prescription of 7–8 days compared with those with a prescription of > 8 days, but the difference was not statistically significant (95% CI: 0.59, 3.7, P = .38).ConclusionMale patients diagnosed with a UTI who were treated with a course of antibiotics for > 7 days were less likely to have a UTI recurrence than patients who were treated for < 7 days. However, there was no statistically significant difference between 7 to 8 days vs. >8 days of antibiotics in terms of recurrence. This study will be continued to increase study power. Determining the best treatment course will reduce healthcare cost and patient morbidity from UTI recurrences. Disclosures All authors: No reported disclosures.

Comparison of Bladder Wall Thickening and Presence of Internal Echoes Within the Bladder for the Diagnosis of Cystitis in Infants

Background: Cystitis is very common in children and the diagnosis is usually made based on clinical findings with laboratory examinations including urinalysis and urine culture. Bladder wall thickening and presence of fine nodule shaped echoes within the bladder are the suggested sonographic findings of cystitis. Objectives: In this study we aimed to compare diagnostic value of bladder wall thickening and presence of fine nodule shaped echoes within the bladder and also perivesical fluid collection for cystitis in infants by correlating urinalysis results. Methods: Urinary tract ultrasound and urinalysis results of a total 1094 infants were retrospectively screened. Patients were classified as groups according to presence of internal echoes in bladder lumen and/or bladder wall thickening and/or perivesical fluid collection. Control group was constituted of the patients who had normal ultrasound results. Also three subgroups of group 2 (the patients with only bladder wall thkening, P2) were classified according to the size of the thickening. Comparison of pathological urinalysis rate of each group with control group was made with statistical analysis. Also subgroups of group 2 (P2) were compared with each other. Results: When compared with control group, all the groups except perivesical fluid group (P1), had statistically significantly higher pathological urinalysis rates (P < 0.05). The pathological urinalysis rates are highest in the thickened wall and echoes in the lumen and perivesical fluid group (P8) and in the thickened wall and echoes in the lumen without perivesical fluid group (P7) (60% and 54.5%, respectively). Also among subgroups of group 2, pathological urinalysis rate was highest in subgroup 3 in which the patients had most thickened bladder wall and the difference was found to be statistically significant (P < 0.005). Conclusions: We suggest that when thickened wall or echoes in the lumen or perivesical fluid collection accompany each other, pathological urinalysis rates increase. Also pathological urinalysis rates increase as the size of thickness of bladder wall increases.

Clinical, Laboratory and Ultrasonographic Findings of Diabetic Dog with Emphysematous Cystitis

Background: Emphysematous cystitis is a rare inflammatory disease of the lower urinary tract characterized by the accumulation of gas within the wall and lumen of the urinary bladder. The clinical manifestations of emphysematous cystitis resemble those of bacterial cystitis, often hindering the differentiation between the two. In this work, we report a case of emphysematous cystitis in a diabetic dog. The diagnosis of cystitis was followed by ultrasonography for the early detection of emphysematous cystitis, which showed the presence of multifocal and irregular hyperechoic interfaces forming a distal reverberation artifact. Case: A 9-year-old female dog was referred to VETCLINIC Veterinary Hospital 24 hours with a history of urinary incontinence, polydipsia, polyuria, and diabetes mellitus. At first, the blood glucose was measured and found to be 376 mg/dL. Blood count, biochemical measurements of alkaline phosphatase (AF), urea, creatinine, and alanine aminotransferase (AAT), urinalysis, urine culture with antimicrobial susceptibility testing, and abdominal ultrasonography were performed. The hematological exams showed that the serum was lipemic and with hemolysis; the values of AAT, AF, and total plasma proteins were above the reference values; hematocrit was below the normal level; erythrocyte rouleaux and thrombocytosis with platelet aggregates were present. Urinalysis showed the presence of traces of proteins, glucose, and occult blood as well as granular and hyaline cylinders and transitional epithelial cells. In urine culture, growth of the aerobic bacteria Klebsiella pneumoniae was observed, being sensitive to most of the antimicrobials. Ultrasonography showed the presence of gas in the wall of the urinary bladder, besides a discrete thickening of the wall, compatible with the diagnosis of emphysematous cystitis. Discussion: The first report of emphysematous cystitis in dogs was made in 1926 in a diabetic dog. Emphysematous cystitis is complicated, characterized by the presence of gas in the wall and lumen of the urinary bladder. It is usually reported in patients with diabetes mellitus. The patient presented with a very high glycemic index (376 mg/dL), in addition to having a history of urinary obstruction and presence of bladder stones, which may have acted as predisposing factors for the onset of emphysematous cystitis. In the present case, ultrasonography was the examination of choice. Hyperechoic reverberation-forming lines, identified as gas present in the topography of the urinary bladder, were easily visualized, as described in the literature. For the treatment of this condition, adequate management of the diet and the correct use of antimicrobials are of fundamental importance since the presence of diabetes mellitus in this patient can present serious complications in the future. This report shows the importance of the use of a combination of diagnostic tools to arrive at the correct diagnosis of the patient.

191. Accuracy of Clinical Indications for Use When Ordering Antibiotics for Cystitis in Community Hospitals

BackgroundDocumentation of clinical indications of antibiotic use is essential for antimicrobial stewardship programs (ASP) to identify targets for improvement and implement syndrome-specific interventions. In 2016, the Centers for Medicare and Medicaid Services proposed a requirement to document clinical indication at the time of antibiotic order entry. Patient safety organizations also support this requirement. We evaluated the accuracy of clinical indications documented at the time of order entry in a sample of antibiotic orders as part of a system-wide ASP initiative.MethodsAntibiotic orders with a documented indication of “genitourinary (GU)–cystitis” were retrospectively reviewed in adult, non-neutropenic hospitalized patients at three community hospitals from April to June 2017. Accuracy of the documented indication was evaluated via chart review. Patient demographics, initial antibiotic selection, ordering service, treatment duration, and infectious diseases (ID) involvement were also evaluated. Data pertaining to the appropriate diagnosis of cystitis was adjudicated by an ID physician.ResultsA total of 122 patients treated for “GU-cystitis” were reviewed (66% female, median age 77 years). Overall, only 25% of orders reviewed were consistent with cystitis per documentation in the chart. However, 42% of patients had evidence of a GU infection other than cystitis. Only 16% of patients possessed criteria for diagnosis of cystitis when adjudicated by an ID physician after additional information was obtained from the chart. About 20% of patients had evidence of asymptomatic bacteriuria and 10% of patients did not have a urinalysis and/or urine culture. The majority of patients were initially prescribed a cephalosporin (70%) or fluoroquinolone (16%). The emergency department was responsible for 52% of orders labeled as cystitis.ConclusionCystitis was inaccurately selected as the indication for most of the orders reviewed. To improve accuracy, minimize provider fatigue and provide better utility to ASPs, the list of available indications should be simplified to include broader terms (i.e., GU instead of GU-cystitis). Appropriate diagnosis and treatment of cystitis remains a challenge and a target for improvement for ASPs.Disclosures All authors: No reported disclosures.

Factors associated with hematuric struvite crystalluria in cats

The aim of the study was to identify any dietary, signalment, geographic and clinical factors associated with hematuric struvite crystalluria (HSC) in a population of cats that visit general care veterinary hospitals in the USA. In total, 4032 cats that had a first-time diagnosis of HSC and 8064 control cats with no history of hematuria or crystalluria were identified from medical records of all cats examined between 2007 and 2011 at 790 US veterinary hospitals. Extracted variables included age, sex, neuter status, breed, diet, urinalysis results and history of cystitis. Potential associations between these variables and HSC were estimated. Controlling for other factors, young cats fed a dry diet had an increased likelihood of HSC relative to young cats fed a non-dry diet. However, as age increased, the likelihood of HSC declined for cats fed a dry diet and increased for cats fed a non-dry diet. Moreover, the odds of HSC were significantly greater when cats were unneutered (vs neutered; odds ratio [OR] 45.52) or had a thin (vs heavy) body condition (OR 23.81), diagnosis of cystitis (OR 2.84), urine protein concentration >30 mg/dl (OR 4.72), alkaline (vs neutral) urine pH (OR 3.34), pyuria (OR 23.67) or bacteriuria (OR 2.24). The present study provides estimates of the strengths of association between HSC and certain signalment and clinical characteristics of cats. This information could help clinicians to perform a more directed screening for struvite crystalluria in certain cat populations. Follow-up studies that build on the findings of this study could explore the clinical importance of HSC in cats.

Evaluation of chromocystoscopy in the diagnosis of cystitis in female donkeys.

Early detection of cystitis in equine is essential to improve the prognosis and outcome of therapy. However, the conventional white light endoscopy is not sufficiently accurate for this purpose. Hence, this study evaluated chromoendoscopy as a recent diagnostic tool for cystitis in female donkeys. For this purpose, 5 apparently normal donkeys (control group) and 5 female donkeys with cystitis (diseased group) were used. Physical and rectal examinations, urine analysis, white light cystoscopy, methylene blue-based chromoendoscopy and histopathology were performed in all animals. Turbid urine exhibiting an alkaline pH and a significant (P = .02) increase in the numbers of RBCs and WBCs was observed in the diseased group compared to the control one. In the control group, white light cystoscopy showed a smooth pale pink glistening mucosa with two openings of the ureters and visible submucosal blood vessels. During chromocystoscopy, faint bluish discoloration of the mucosal surface with clearly visible submucosal blood vessels was detectable. These findings were correlated with the histopathological findings of the biopsies collected from the urinary bladder. In the diseased group, white-light cystoscopy showed clearly visible blood vessels, mildly hyperaemic mucosa in focal or diffuse forms and small vesicle formation. Chromocystoscopy revealed dark bluish oedematous and irregular mucosa either in a focal form or a diffuse form (marbled appearance) with deeply stained submucosal blood vessels. Histopathologically, the urothelium was hyperplastic with squamous metaplasia and the lamina propria was infiltrated with few leukocytes and congested blood vessels. Small bluish dots representing the absorbed methylene blue dye were seen in the inflamed areas against the lightly stained mucosa of the bladder. Severe diffuse necrotic cystitis was also seen with bacterial aggregations on the surface. Gram’s staining revealed both gram positive bacilli and Gram positive coccobacilli. In conclusion, chromoendoscopy is a helpful tool for early diagnosis of cystitis in female donkeys and enables targeted biopsies, which improves the prognosis and outcome of therapy.

The Improving Outcomes of UTI Management in Long-Term Care Project (IOU) Consensus Guidelines for the Diagnosis of Uncomplicated Cystitis in Nursing Home Residents

ObjectivesTo identify a set of signs and symptoms most likely to indicate uncomplicated cystitis in noncatheterized nursing home residents ≥65 years of age using consensus-based methods informed by a literature review. DesignLiterature review and modified Delphi survey with strict inclusion criteria. Setting and ParticipantsExpert panel of 20 physicians certified in geriatric medicine and/or medical direction, actively practicing in post-acute and long-term care settings. MethodsThe authors performed a literature review to produce a comprehensive list of potential signs and symptoms of presumptive uncomplicated cystitis, including nonspecific “quality control” items deemed unlikely to indicate uncomplicated cystitis. The expert panel rated their agreement for each sign/symptom using a 5-point Likert-type scale (1 = strongly disagree to 5 = strongly agree). Agreed upon signs and symptoms were summarized using a diagnostic algorithm for easy clinical use. ResultsThe literature review identified 16 signs and symptoms that were evaluated in 3 Delphi survey rounds. The response rate was 100% for round 1 and 95% for the second 2 rounds. Consensus agreement for inclusion was achieved for dysuria on round 1 with exclusion of the 3 quality controls, and “offensive smelling urine.” Consensus in the second round was reached for including 4 additional items (gross hematuria, suprapubic pain, urinary frequency, and urinary urgency). Round 3 evaluated dysuria alone and combinations of symptoms. Consensus that dysuria alone is sufficient for diagnosis of cystitis was not reached. Conclusions/ImplicationsThe panel identified 5 signs and symptoms likely indicative of uncomplicated cystitis in nursing home residents and developed a diagnostic algorithm that can be used to promote antibiotic stewardship in nursing homes. Given similarities in populations, the algorithm may also be applicable to the older adult and the broader post-acute/long-term care populations.

Survival analysis to evaluate associations between periodontal disease and the risk of development of chronic azotemic kidney disease in cats evaluated at primary care veterinary hospitals.

OBJECTIVE To examine potential associations between periodontal disease (PD) and the risk of development of chronic azotemic kidney disease (CKD) among cats and determine whether the risk of CKD increases with severity of PD. DESIGN Retrospective cohort study. ANIMALS 169, 242 cats. PROCEDURES Cats were evaluated ≥ 3 times at any of 829 hospitals from January 1, 2002, through June 30, 2013. Cats with an initial diagnosis of PD of any stage (n = 56,414) were frequency matched with cats that had no history or evidence of PD (112,828) by age and year of study entry. Data on signalment, PD, and other conditions potentially related to CKD were extracted from electronic medical records. Cox proportional hazards modeling was used to estimate the association of PD with CKD after controlling for covariates. RESULTS PD was associated with increased risk of CKD; risk was highest for cats with stage 3 or 4 PD. Risk of CKD increased with age. Purebred cats had greater risk of CKD than mixed-breed cats. General anesthesia within the year before study exit and diagnosis of cystitis at any point prior to study exit (including prior to study entry) were each associated with increased CKD risk. Diagnosis of diabetes mellitus or hepatic lipidosis at any point prior to study exit was associated with decreased CKD risk. CONCLUSIONS AND CLINICAL RELEVANCE The findings supported the benefit of maintaining good oral health and can be useful to veterinarians for educating owners on the importance of preventing PD in cats.

Staphylococcus saprophyticus: Which beta-lactam?

BackgroundStaphylococcus saprophyticus is resistant to the drugs most often used for the empirical treatment of urinary tract infections (UTI). The adequacy of antimicrobial treatments prescribed for UTI due to S. saprophyticus is not usually questioned. This study described the epidemiology of such infections and assessed the susceptibility of S. saprophyticus to ceftriaxone and amoxicillin–clavulanic acid. MethodsMethicillin-susceptible S. saprophyticus (MSSS) isolated from clinical samples between November 2014 and July 2016 were included. Clinical data were recorded. The minimum inhibitory concentrations (MICs) of amoxicillin–clavulanic acid and ceftriaxone were measured for these MSSS strains and for 17 randomly selected methicillin-susceptible Staphylococcus aureus (MSSA) strains. ResultsOf the S. saprophyticus isolates from urine, 59.5% were associated with a diagnosis of cystitis and 33.3% with pyelonephritis. Sixty percent of S. saprophyticus cystitis cases and 25% of pyelonephritis cases were given an inappropriate antibiotic regimen. The MICs of ceftriaxone ranged from 4 to >32μg/ml for MSSS, and from 1.5 to 4μg/ml for MSSA. ConclusionsMany UTIs were treated with an empirical antibiotic therapy that was ineffective for S. saprophyticus, revealing that S. saprophyticus is an aetiology that is insufficiently considered in UTI. High MICs for ceftriaxone in MSSS were observed, which raises questions about the use of this antibiotic in UTIs due to S. saprophyticus.

Hyperbaric Oxygen Therapy for Radiation Cystitis: Evaluation of Treatment Efficacy Seen During Post-treatment Follow-Up

Hyperbaric oxygen therapy has been reported to be effective in the treatment of delayed soft tissue radiation injuries. HBOT stimulates angiogenesis, improves tissue oxygenation, stimulates stem cell activity, and decreases fibrosis. However, few follow-up data are available. This study assesses follow-up outcomes at one clinical center for patients with radiation cystitis receiving HBOT. Patients with radiation cystitis receiving HBOT at our facility between January 2006 and December 2014 were included. HBOT involved patients breathing nearly 100% oxygen for 90 minutes in a hyperbaric chamber pressurized to 2.4 atmospheres absolute (ATA). Data recorded included patient characteristics, type of cancer, dose of radiotherapy (RT) received, time between RT and diagnosis of cystitis, time between diagnosis of cystitis and HBOT, and the number of HBOT sessions completed. Hyperbaric physicians evaluated patients’ symptoms before, during, and upon completion of HBOT. After HBOT, radio-oncologists and urologists conducted follow-up evaluations. Treatment was considered effective if symptoms were resolved or improved. Unimproved or worsening symptoms were classified as failure of treatment. A bivariate analysis was made for the number of exposures and the effectiveness of HBOT. Data are presented as mean±SD with range or percentage as appropriate. Significance was accepted at P<0.05. Thirty-five patients (67±10 [29-84] years of age at start of HBOT) received 43±9 (29-60) hyperbaric treatments. The majority of patients had hematuria as the principal symptom (n=34; 97%), were male (n=30; 86%), non-smoking (n=32; 91%), and had prostate cancer (n=30; 86%). The radiation dose received was 67±17 (33-120) Gy (EQD2). Post-HBOT follow-up ran for 29±21 (1-60) months. The time between RT and diagnosis was 42±39 (1-146) months. The time between diagnosis of cystitis and HBOT was 21±50 (0-298) months. Twenty-three patients had tried pentosan polysulfate, 18 electrofulguration, and 8 needed transfusions. There was no difference in symptom resolution if patients had 40 or 50 HBO exposures. At 6 months, 91% (n=32) had improved or resolved symptoms. Overall, treatment was effective in 71% (n=25) of cases. Conversely, 29% (n=10) of patients had a failure of treatment, four at ≤3 months of follow-up, and 6 at 22±9 (12-36) months. Six patients with failure of treatment returned to their pre-HBOT condition, and 4 had worsening symptoms. Seven patients (20%) with failure of treatment needed surgery post-HBOT: 5 had cystectomy, 1 cystoprostatectomy, and 1 pelvic exenteration. HBOT was effective in the majority of patients with radiation cystitis as evidenced through a mean 2.5-year follow-up period. Patients that needed surgical management presented an early failure to HBOT. Studies with longer follow-up periods are still required.

Significance of Interleukin-8 in Cystitis and Schistosomal Chronic Cystitis

One of the important mediators of early inflammatory response in cystitis and an agent for attraction of neutrophils to the inflammation site is IL-8, in addition to its role in regulation angiogenesis. This study was carried out to assess the level of IL-8 biomarker in urine of cystitis patients (schistosomal chronic cystitis and non schistosomal cystitis).&#x0D; Eighty eight Iraqi individual were divided to 50 cystitis patients and 38 healthy control, of whom urine sample and bladder biopsy were collected. Diagnosis of cystitis patients carried out by cystoscopy followed by histopathological examination and was classified to schistosomal chronic cystitis and non-schistosomal cystitis. Urine IL-8 level of studied groups was measured by ELISA test.&#x0D; According to the result of ELISA technique, the mean urine concentration (pg/ml) of IL-8 increased significantly in cystitis patients 224.86 pg/ml than healthy controls 51.70 pg/ml. In regard to the age of cystitis patients urine level of this marker was significantly different (P&lt;0.05), but there was not any significant increase in IL-8 urine level according to sex, while IL-8 was with significant increase in Schistosomal chronic cystitis than non-Schistosomal cystitis. Lastly urine IL-8 showed specificity in diagnosis of cystitis 91.39% and more sensitivity 96.34%.&#x0D; Result of this study showed significant increase in urinary IL-8 concentration in cystitis patients, with significant correlation between IL-8 level with Schistsoma infection and age.

Evaluation of the Risk of Nitrofurantoin Lung Injury and Its Efficacy in Diminished Kidney Function in Older Adults in a Large Integrated Healthcare System: A Matched Cohort Study.

To determine the risk to older adults of lung injury associated with treatment of cystitis using nitrofurantoin and the risk of treatment failure in the presence of diminished creatinine clearance (CrCl). Retrospective, matched cohort. Integrated healthcare system. Individuals aged 65 and older with a diagnosis of cystitis between 2007 and 2012 who were given nitrofurantoin (N = 13,421) were matched 1:3 on age, sex, race and ethnicity, and prescription date with individuals who were given other antibiotics for cystitis. Conditional logistic regression determined the association between nitrofurantoin and lung injury in the matched cohort. In participants exposed to nitrofurantoin, chronic treatment was compared with acute treatment using multivariable logistic regression. Treatment failure was compared in three CrCl groups. Nitrofurantoin exposure was not statistically significantly associated with lung injury (adjusted risk ratio (aRR) = 0.90, 95% confidence interval (CI) = 0.80-1.00), but chronic nitrofurantoin therapy was associated with greater risk of lung injury than acute exposure (aRR = 1.53, 95% CI = 1.04, 2.24). Treatment failure rates did not differ according to CrCl. This large, retrospective, matched-cohort study conducted in older adults supports the 2012 American Geriatrics Society Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults recommendations against the use nitrofurantoin for long-term suppressive treatment of cystitis but not the recommendation against its use in poor renal function because of the risk of treatment failure.

Risk Factors Associated with Severity and Outcomes in Pediatric Patients with Hemorrhagic Cystitis

Hemorrhagic cystitis is a complication of treatment of pediatric cancer with considerable variation in severity and morbidity. This study presents an analysis of hemorrhagic cystitis severity and treatment outcomes in a large pediatric population. Patients with hemorrhagic cystitis treated at St. Jude Children's Research Hospital® were identified from 1990 to 2010. Demographic data were gathered along with information pertaining to initial primary diagnosis, hemorrhagic cystitis diagnosis and treatment, and mortality. Statistical analyses were performed to evaluate associations between risk factors and severity of hemorrhagic cystitis as well as treatment outcomes. Of the 285 patients who met inclusion criteria 54% were male. Mean age was 11.41 years. Mean time from initial primary diagnosis to hemorrhagic cystitis onset was 29 months. Noninvasive treatment was performed in 246 patients (86%) and operative intervention was required in 14 (4.9%). Bivariate analysis demonstrated that pelvic radiation therapy (p = 0.0002), any radiation therapy (p = 0.005), acute lymphocytic leukemia (p = 0.01), bone marrow transplantation (p = 0.0225), cyclophosphamide exposure (p = 0.0419) and BK virus positivity (p = 0.0472) were predictors of higher grade hemorrhagic cystitis.Factors correlating with the need for invasive management on bivariate analysis included pelvic radiation therapy (p = 0.0266), bone marrow transplantation (p=0.0007), hematological malignancy (p = 0.0066), ifosfamide exposure (p=0.0441) and male gender (p = 0.0383). Multivariate analysis showed independent effects of pelvic radiation therapy (p = 0.001) and delayed onset of hemorrhagic cystitis (p = 0.0444). Severity of hemorrhagic cystitis and failure of noninvasive management correlate with several identifiable risk factors. Prospective identification of patients with these risk factors may allow for targeted early intervention in those at highest risk.

Low urinary bacterial counts: do they count?

In their article which appears in this issue of Pediatric Nephrology, Dr. S. Swerkersson and co-workers claim that as many as one in every five infants with a true episode of urinary tract infection (UTI) will be missed with the commonly used cut-off level of ≥10(5) colony forming units (CFU)/mL. This controversial finding is supported by the results of seven previous studies including a total of 1587 children. Dr. E.H. Kass, who in the 1950s suggested the presently used cut-off level, knew at the time that it excluded a number of patients with a true infection. Later studies in adult patients also showed that up to 46–49% of women with a likely diagnosis of cystitis had low bacterial counts. These findings can, if true, improve our understanding of cases of unexplained postinfectious renal scarring. Children with low bacterial counts during an acute infectious episode have a significant risk of receiving delayed or even no antimicrobial treatment. The results of scientific studies are also confounded if 20 % of the subjects with a true infection are wrongly included in a control group diagnosed as having no UTI due to low bacterial counts. This problem cannot be easily solved by lowering the cut-off level and generally accepting that any bacterial count signifies a Btrue^ infection as this approach will drastically reduce the specificity of the culture result. Instead, as many as possible urine samples for culture should be collected from babies, infants and small children with a suprapubic bladder puncture, or a catheterised sample. In such samples bacterial counts as low as 103 CFU/mL are generally regarded as significant. In many cases, however, the only possibility is a Bclean catch^ or bag sample. In these situations, the treating physician needs to take all relevant clinical and laboratory parameters into account and if clinically important data support the diagnosis of a UTI not disregard this diagnosis based only on low bacterial counts. C-reactive protein or procalcitonin can, in a febrile child, help the physician differentiate between a febrile bacterial UTI and a viral infection. A positive nitrite test provides, albeit with a low sensitivity, strong support for a UTI diagnosis.

O descortinar de um diagnóstico de hematúria: relato de caso

Introduction: The prevalence of lower urinary tract symptoms (LUTS) increases with age. They have significant impact on quality of life and commonly cause adults to seek medical care. When a middle-aged man presents with LUTS, we must consider diseases that affect the prostate, urethra, bladder and detrusor muscle. Case report: A 50 year-old male welder, with a previous history of dyslipidemia, 3,5 pack-years of smoking, and an episode of renal colic with renal microlithiasis came to his Family Physician in October 2012. He complained of dysuria, urinary frequency, terminal hematuria, and hypogastric pain. A diagnosis of cystitis was made and antibiotic therapy was prescribed after obtaining a urine culture. The urine culture was negative. In the absence of prostration, fever, and purulent discharge, and given a previous history of urolithiasis, this episode was reinterpreted as a second episode of renal colic. In August 2013, the patient presented with terminal dribbling, sporadic dysuria, and hematuria on urine dipstick analysis. An assay of total prostate specific antigen, an analysis of urinary sediment, and a transabdominal vesicoprostatic ultrasound were ordered. One month later a bulky neoplastic lesion of the bladder was found on ultrasound examination. Comment: Despite the presence of risk factors for bladder carcinoma (previous smoking and age over 35 years), this diagnosis was not considered at the initial consultation. On follow-up, other confounding factors emerged, including a past history of renal stones and the presence of symptoms suggestive of other diseases more common in this age group. The case report explores the complexity of the differential diagnosis of LUTS in an adult male. This is a common complaint in Family Medicine consultations, pointing to a set of disorders with defined diagnostic and therapeutic guidelines.

BK Virus Hemorrhagic Cystitis Is Associated with Graft Versus Host Disease and Increased Health Care Resource Utilization in Patients Undergoing Allogeneic Stem Cell Transplantation

Background BK virus (BKV) is a polyomavirus that carries up to a 90% sero-prevalence in the general population. After infection the virus enters a latent phase in the renourinary epithelium. In hematopoietic stem cell transplant patients, BKV reactivation may lead to hemorrhagic cystitis with an incidence of 7%-70%. Aside from BKV, hemorrhagic cystitis (&gt;72 h) has been linked to patient age, conditioning regimen, graft versus host disease (GVHD), and unrelated/mismatch donor. Symptoms range from dysuria to severe hemorrhage leading to clot formation, urinary obstruction and renal impairment. These complications have been shown to impact length of hospitalization, cost of care, and mortality. The incidence and impact of hemorrhagic cystitis in patients receiving fludarabine (Flu), busulfan (Bu)and anti-thymocyte globulin (ATG) conditioning is unknown. We carried out this study to determine the incidence and its effect on patient outcomes including overall survival, relapse, GVHD, and health care resource use. Patient Selection and Methods We reviewed the medical records of 661 consecutive patients undergoing allogeneic stem cell transplant from January 1, 2003 to January 1, 2013. Hemorrhagic cystitis was diagnosed with symptoms (cystitis with microscopic or macroscopic hematuria, in the absence of other causes such as bacterial/fungal infection or nephrolithiasis) of at least 1 week following stem cell transplant. Microbiological confirmation was obtained routinely after 2005. Controls were matched to cases in a 2:1 ratio in the following priority: age (+/- 10 years), donor type, disease type, GVHD prophylaxis and disease status. All cases received FluBuATG +/- total body irradiation (400 cGy), and all except two received methotrexate (MTX) and cyclosporine (CsA) for GVHD prophylaxis (only received CsA). Results Hemorrhagic cystitis was identified in 117/661 transplant recipients over ten years, for an incidence of 17.7%. After removing cases with a previous transplant, unsuitable matched controls, and incomplete data, 94 evaluable cases were matched to 188 controls. The cohort median age was 50.25 years. Diagnoses included AML (38.3%), ALL (21.3%), MDS (11.7%), CLL (13.8%), NHL (6.4%) and myeloproliferative syndromes (6.4%). Disease statuses included CR1 (31.9%, CR2 (19.1%), untreated (14.9%), PR (13%) and primary refractory (4.3%). Of the cases, 77 of 83 (92.8%) tested positive for BKV in urine by PCR. Median onset was 45 days (range 12 – 279 days). Median BK viral copies was 2242.5 x 106copies/mL (range 0.285 to 4530000). Cases had higher proportions of significant (Grade 2-4) acute GVHD (43.6% vs 27.0%, P=0.0052) and chronic GVHD (cGVHD) requiring steroids (34.9% vs 18.6%, P=0.004). The median onset of significant acute GVHD (aGVHD) was 27 days (range 11 – 103 days), and for cGVHD was 108 days (range 29 – 236 days). Out of 41 aGVHD cases, 8 occurred after BKV hemorrhagic cystitis diagnosis while 23 occurred prior. In 30 cGVHD cases, 23 occurred after BKV hemorrhagic cystitis diagnosis while 7 occurred prior. Cases also had longer hospital stays in the 6 months following transplant (65.5 days vs 40.5 days, P&lt;0.0001). There were no differences in regards to overall survival (HR=1.088, 95% CI 0.7519-1.580), or relapse-free survival (HR=1.057, 95% CI 0.7364-1.519). Evaluating all patients with significant aGVHD, there was no difference in regards to overall survival between controls and cases (HR=0.8042, 95% CI 0.5205-1.205). This was similar for with patients with cGVHD (HR=0.9949, 95% CI 0.6020-1.643) Conclusions This retrospective study shows that BKV hemorrhagic cystitis is a common complication of allogeneic stem cell transplant. While it does not impact overall survival even in ATG-conditioned patients, it is associated with GVHD and longer hospitalizations. Future studies are warranted to determine how BKV hemorrhagic cystitis is influenced by GVHD. Additionally, studies into the pathophysiology of BK virus reactivation with the eventual goal of developing prophylaxis, preemptive therapy or treatment are also warranted. Disclosures No relevant conflicts of interest to declare.