Diagnosis Of Pyelonephritis Research Articles

Chinese Herb-Resistant Clinical Isolates ofEscherichia coli

Many Chinese herbal formulations are used in the treatment of urinary tract infection. Clinical isolates of Escherichia coli (E. coli) resistant to Chinese herbs have been identified rarely. Report here is a case in which Chinese herbs-resistant E. coli isolate was identified. The strain of E. coli C16 was isolated from urine of a 72-year-old woman with a diagnosis of pyelonephritis. Standard disc diffusion methodology was used to test the Chinese herbal decoction against E. coli C16. The minimum inhibitory concentration value was 0.1 g/mL. The minimum bactericidal concentration value was 0.2 g/mL. The decoction was orally administered for 4 weeks. The therapeutic regimen was well tolerated initially. At the end of 4 weeks, the disease relapsed. E. coli C16 was isolated again, which was resistant to herbal solution. This case illustrates that excessive exposure to Chinese herbs used in unchanging standard formulations can also lead to bacterial resistance. Appropriate clinical use of Chinese herbs is imperative.

When Is a Chronic Wound Infected?

Humans are not germ free. In fact, the number of bacterial cells in our body exceeds the number of all our other cells. We live in relative harmonywith our bacterial flora. Therefore, the presence of bacteria alone is not an indication of infection. Intact skin is one of the major barriers to development of infection. A break in the skin; that is, a wound, opens the possibility of bacterial penetration and infection. The consequences of wound infection are formidable: delayed wound healing, extension of infection into muscle (necrosis) or bone (osteomyelitis) or bloodstream (sepsis), and increased mortality.1 Thus, determining when infection is present is critical to effective wound management. Onewould suppose that criteria fordiagnosingawound infection would be widely recognized, given the frequency of wound infections in the population. However, a reviewof the literature indicates that this is not the case. Considerable research over the years has simply elaborated how complicated this really is.2 What is clear is that acute wounds, such as surgical wounds or full-thickness burn injuries, differ considerably from chronic wounds, such as pressure ulcers, diabetic ulcers, venous stasis ulcer, or arterial ulcers.3 Moreover, it is increasingly clear that the symptoms/signs of infection differ among these chronic wounds themselves. How do we determine that a wound is infected? The diagnosis of awound infection requires two essential criteria: The presence of bacteria in the wound AND evidence that the bacteria is producing tissue damage (usually in the form of an inflammatory response). In the past 5 decades, a large amount of research has focused on the concept of “bacterial burden.” For example, a quantitative relationship between bacteria and urinary tract infection is widely accepted. A concentration of greater than 100,000 organisms per milliliter of urine is necessary to establish the diagnosis of pyelonephritis. If fewer than 100,000 organisms per milliliter are present, asymptomatic bacteriuria is present.4 The consequence of bacterial burden in acute wounds and in wounds healing by secondary intention is well established. Data

A guideline for the inpatient care of children with pyelonephritis

BACKGROUND AND OBJECTIVES:Febrile urinary tract infections and pyelonephritis are common in children and frequently lead to hospitalization for management, especially in the child who appears toxic. The American Academy of Pediatrics (AAP) practice parameter on the diagnosis, treatment and evaluation of the initial urinary tract infection in febrile infants and young children provides experience and evidence-based guidelines for the practitioner caring for children between the ages of 2 months to 2 years. No established guideline exists for older children and the AAP guideline does not specifically focus on inpatient care.METHODS:We conducted a comprehensive review of recently published literature and practice guidelines to develop a consensus on the inpatient diagnosis and management of children with pyelonephritis.RESULTS:Eight recommendations are proposed for the diagnosis and management, including revised guidelines for the imaging studies postpyelonephritis on the basis of current best evidence.CONCLUSION:Proper diagnosis of pyelonephritis, timely initiation of appropriate therapy and identification of children at risk for renal injury will help to reduce immediate as well as long-term complications due to chronic kidney disease.

Magnetic resonance urography in pediatric urology

Magnetic resonance urography (MRU) has evolved into an effective imaging tool for the evaluation of the urinary tract in children. The goal of this article is to describe current techniques and applications of MRU and to review recent advances. MRU is most commonly applied to the evaluation of hydronephrosis and provides valuable insight into a wide range of obstructive uropathies. MRU was shown to be superior to renal scintigraphy for the diagnosis of pyelonephritis and renal scarring. The use of MRU for the assessment of urolithiasis, vesicoureteral reflux, renal trauma, and fetal urinary tract abnormalities is limited and technical refinements are required. Judicious use of gadolinium-based contrast agents in patients at risk for nephrogenic systemic fibrosis was recently shown to avoid new occurrences. Potential future applications include virtual endoscopy and MRU-guided procedures. MRU has the potential to revolutionize imaging of the urinary tract in children. It integrates exquisite anatomical information with a variety of functional data and avoids ionizing radiation. MRU is increasingly employed as a problem solver when conventional imaging studies remain inconclusive and its growing application will likely improve availability and cost in the future.

Xanthogranulomatous pyelonephritis: critical analysis of 30 patients

Xanthogranulomatous pyelonephritis (XGP) is a chronic inflammatory condition of the kidneys. Nevertheless, disparities between the pre-operative and pathological diagnoses are frequently encountered. We reviewed all patients with XGP over a 17-year period to identify and characterize the pre-operative and pathological characteristics of the disease in our patients. A comprehensive review of all nephrectomy patients with a pre-operative diagnosis of pyelonephritis at National Taiwan University Hospital from 1991 to 2008 with the pathological diagnosis of XGP was conducted to demonstrate the clinical and radiological characteristics of XGP. XGP was diagnosed in 30 (18.6%) of the 160 nephrectomies performed for pyelonephritis. Of the 30 patients with XGP, 25 were women (83.3%) and 20 (66.7%) were overweight (body mass index>23). Their mean age was 55.17years. The average serum creatinine level was 1.68mg/dL. The image findings included renal calculi (56.7%), staghorn stones (26.7%), and spread of the disease to the retroperitoneum and psoas muscle (33.3%). Escherichia coli (36.7%) was the most prevalent pathogen. The mortality of the two-stage surgical treatment was zero, and morbidity developed in only 1 patient (4.8%). The key to accurate pre-operative diagnosis is to keep risk factors in mind such as age, sex, and renal calculi. Clinicians should maintain a high suspicion of XGP for early recognition and be aware of the care of chronic kidney disease. Finally, the association between XGP and central obesity warrants further research.

Mizoribine for renal sarcoidosis: effective steroid tapering and prevention of recurrence

Sarcoidosis is a systemic disease of unknown etiology that is characterized by chronic non-caseating granulomatous inflammation with tissue destruction. It is an uncommon disease in children, and renal sarcoidosis in particular is very rare in adults and children. A 17-year-old boy with renal sarcoidosis was referred to our hospital with an initial diagnosis of pyelonephritis. Prior treatment with various antibiotics had not been effective, but tentative oral daily prednisolone (PSL) had partially ameliorated his symptoms, although the symptoms recurred during steroid tapering. We detected non-caseating granulomatous interstitial nephritis and numerous sclerotic glomeruli in a second biopsy specimen, compatible with the diagnosis of renal sarcoidosis. The patient was treated with pulsed methyl-prednisolone and oral daily doses of PSL and mizoribine (MZR). During the treatment with MZR, the PSL was successfully tapered, and the patient has since presented no signs of recurrence. Our treatment of this patient shows that treatment with MZR can allow steroid sparing and prevent recurrence in a patient with sarcoidosis.

Prevalence and Risk Factor Analysis of Trimethoprim‐Sulfamethoxazole– and Fluoroquinolone‐ResistantEscherichia coliInfection among Emergency Department Patients with Pyelonephritis

High rates of resistance to trimethoprim-sulfamethoxazole (TMP-SMX) among uropathogenic Escherichia coli are recognized, and concerns exist about emerging fluoroquinolone resistance. Adults presenting to 11 US emergency departments with (1) flank pain and/or costovertebral tenderness, (2) temperature >38 degrees C, and (3) a presumptive diagnosis of pyelonephritis were enrolled; patients for whom 1 uropathogen grew on culture were analyzed. Epidemiologic and clinical data were collected at the time of care. The prevalence of E. coli in vitro antibiotic resistance and risk factors associated with TMP-SMX-resistant E. coli infection were determined. Among 403 women with uncomplicated pyelonephritis caused by E. coli, the mean site rate of E. coli resistance to TMP-SMX was 24% (range, 13%-45%). Mean site rates of E. coli resistance to ciprofloxacin and levofloxacin were 1% and 3%, respectively. Only TMP-SMX exposure within 2 days before presentation and Hispanic ethnicity were associated with E. coli resistance to TMP-SMX (compared with resistance rates of approximately 20% among women lacking these risk factors); antibiotic exposure within 3-60 days before presentation, health care setting exposure within 30 days before presentation, history of urinary tract infections, and age >55 years were not associated with E. coli resistance to TMP-SMX. Among 207 patients with complicated pyelonephritis, mean site rates of E. coli resistance to ciprofloxacin and levofloxacin were 5% and 6%, respectively. These results suggest that the prevalence of TMP-SMX-resistant infection among patients with uncomplicated pyelonephritis is > or =20% in many areas of the United States, and risk stratification cannot identify patients at low risk of infection. Rates of fluoroquinolone-resistant E. coli infection appear to be low among patients with uncomplicated pyelonephritis but higher among those with complicated infections. Fluoroquinolones should remain to be the preferred empirical treatment for women with uncomplicated pyelonephritis.

Antibiotic Prophylaxis Is Not Effective for Vesicoureteral Reflux

The efficacy of antibiotic prophylaxis in children with vesicoureteral reflux (VUR) following a diagnosis of pyelonephritis remains controversial. In

Pyelonephritis, renal scarring, and reflux nephropathy: a pediatric urologist’s perspective

Imaging of children with a clinical diagnosis of pyelonephritis is performed to characterize the extent of the infection, to identify associated renal injury and to uncover risk factors for future infections and renal damage. Although there is general agreement regarding the need for parenchymal imaging and the need to exclude processes that are either functionally or anatomically obstructive, there is controversy regarding the need for routine cystography, especially when parenchymal involvement has not been documented. A protocol that limits the use of cystography for evaluation of urinary tract infections must assume that the diagnosis of reflux is at least of variable clinical significance. It is now clear that vesicoureteral reflux and reflux nephropathy represent a diverse population that includes both congenital and acquired processes. MR imaging will improve our understanding of vesicoureteral reflux, pyelonephritis and renal scarring and might help us to identify and manage those patients most at risk for recurrent infections and renal injury. To recognize the potential contributions of this newer imaging technique it is helpful to look at our understanding of the pathophysiology of pyelonephritis, reflux and reflux nephropathy.

Magnetic resonance urography in pediatric urology

Purpose of review Magnetic resonance urography (MRU) has emerged as a powerful diagnostic tool in the evaluation of the pediatric genitourinary tract. The purpose of this review is to familiarize the reader with the basic techniques, strengths and limitations, as well as the current and potential future applications of MRU in pediatric urology. Recent findings MRU can provide detailed anatomical information and assess renal function and drainage in a single study. MRU does not employ ionizing radiation and may be utilized in patients with iodine-based contrast allergy or impaired renal function. MRU has been most often applied to the evaluation of hydronephrosis and provides valuable insight into a wide range of obstructive uropathies. MRU was shown to be superior to renal scintigraphy for the diagnosis of pyelonephritis and renal scarring. The use of MRU for the assessment of urolithiasis and vesicoureteral reflux is limited and technical refinements are required. Potential future applications include fetal MRU, virtual endoscopy, and MRU-guided procedures. The development of new contrast agents and new image-processing software will further enhance the diagnostic potential of MRU in pediatric urology. Summary MRU is currently thought of as a problem-solving tool to define anatomy and function when conventional methods fall short. This technique is likely to emerge as the imaging modality of choice for children with complex genitourinary pathology.

Ceftriaxone associated nephrolithiasis: a prospective study in 284 children

Urinary tract calculi have been reported to account for between 1 in 1,000 and 1 in 7,600 hospital admissions in children in the USA. The annual incidence of urolithiasis in patients older than 10 years is 109 per 100,000 of the population in men and 36 per 100,000 of the population in women in Minnesota. The use of various medications is considered to be one of the etiologic factors of nephrolithiasis. Ceftriaxone is a widely used third-generation cephalosporin that is generally considered very safe, but complications such as biliary pseudolithiasis, and rarely, nephrolithiasis have been reported in children. There is limited information about urolithiasis as a side effect of ceftriaxone. The aim of this study was evaluation of the incidence of nephrolithiasis following ceftriaxone therapy in children. This quasi-experimental before and after study was conducted in Mofid Children's Hospital between 2003 and 2005. All patients were treated with 75 mg/kg intravenous ceftriaxone. Diagnosis of pyelonephritis was based on standard criteria. The first renal ultrasonography was performed on the first or second day of admission and was repeated on the last day of treatment. We also evaluated complicated patients for the third time with renal ultrasonography 3 months after treatment. Stone-forming patients underwent metabolic kidney stone risk factor evaluation. We evaluated 284 patients with pyelonephritis, 185 girls and 99 boys. The first ultrasonography was normal in all of our patients. On the second ultrasonography renal stones were reported in 4 out of 284 cases (1.4% and CI=0.96-1.83%). Underlying metabolic risk factors could not be identified in stone-forming patients. Follow-up ultrasonography 3 months later was normal. The results of our study suggest that ceftriaxone-treated patients may be at an increased risk of kidney stone formation. Stones passed spontaneously in all affected patients so the use of this effective drug can be safely continued. Close monitoring of ceftriaxone-treated patients with regard to kidney stone formation is recommended.

The role of magnetic resonance imaging in pediatric urology

Magnetic resonance imaging has emerged as a powerful diagnostic tool for the imaging of the pediatric genitourinary tract. The aim of this review is to familiarize the reader with the current applications and basic techniques utilizing magnetic resonance imaging in pediatric uroradiology. Magnetic resonance imaging can provide both a detailed anatomic and functional assessment of the pediatric genitourinary tract in a single study without the use of ionizing radiation. Magnetic resonance urography combines static and dynamic evaluation of the urinary tract following contrast administration and has been most often applied to the evaluation of hydronephrosis. In addition to unparalleled anatomic assessment, it allows for the evaluation of glomerular filtration rate, renal transit time, and differential renal function. It also provides unique insights into a wide range of obstructive uropathies and has been demonstrated to be useful in the evaluation of complex genitourinary anomalies. Magnetic resonance voiding cystourethrography has been used to rule out vesicoureteral reflux. Magnetic resonance imaging has also been demonstrated to be superior to nuclear scintigraphy for the diagnosis of pyelonephritis and renal scarring. Magnetic resonance imaging has emerged as a powerful tool for the diagnosis of pediatric genitourinary anomalies. It provides functional and anatomic assessment with a single procedure that in most cases is superior to conventional procedures. Magnetic resonance imaging will probably become the modality of choice for the imaging of pediatric genitourinary tract anomalies.

Vesicoureteral reflux increases the risk of renal scars: a study of unilateral reflux

The aim of this study was to assess the impact of vesicoureteral reflux (VUR) on renal scar following acute pyelonephritis by comparing the refluxing renal units with nonrefluxing renal units in children with unilateral primary VUR. Forty-eight children with unilateral primary VUR diagnosed after the first pyelonephritis were enrolled. Mean age of patients was 1.0+/-1.6 years (29 boys and 19 girls). All patients underwent renal ultrasonography and renal 99 m-technetium dimercaptosuccinic acid (DMSA) scan within three days following the diagnosis of pyelonephritis, and voiding cystourethrography (VCU) was performed soon after fever subsided and the infection was controlled. The DMSA scan was rechecked six months after the initial study when the first scan showed a renal defect. The first DMSA showed renal defects in 34 (70.8%) out of 48 of the refluxing renal units and in 13 (27.1%) out of 48 of the nonrefluxing renal units (P<0.01, OR: 6.54). At six months after the infection, 23 (47.9%) out of 48 refluxing renal units and seven (14.6%) out of 48 nonrefluxing renal units had renal scars on DMSA scan (P<0.01, OR: 5.39). The prevalence of renal scars did not vary significantly according to the grade of VUR. The CRP level on admission was significantly higher in patients with acute renal defect and scar. In conclusion, VUR increases the risk of post-pyelonephritic renal scars in children.

Development of kidney scars after acute uncomplicated pyelonephritis: relationship with clinical, laboratory and imaging data at diagnosis

Acute pyelonephritis is a potential cause of kidney scars. To evaluate the relationship between clinical, laboratory and imaging data and the development of kidney scars in acute pyelonephritis. All consecutive patients hospitalized for acute uncomplicated pyelonephritis in our nephrology unit from June 1996 to June 2004 were considered: 58 females, median age 25.6 years (16-52). Diagnosis of pyelonephritis required parenchymal lesions shown by CT or NMR scan. The lesions were bilateral in 17.2% (10/58) patients, unilateral, but multifocal in 81.0% (47/58); at CT or NMR, 65.5% of the lesions were classified as simple, 19% with tendency to colliquation and 15.5% abscessual. The median interval between first symptoms and diagnosis was 5 days (1-25); at referral, only 20.7% had a positive urine culture and 94.8% (55/58) had undergone previous antibiotic treatment. The therapeutic protocol required intravenous therapy for > or = 2 weeks, followed by 2-4 weeks of oral therapy. At 6-8 months, the prevalence of kidney scars was 29.3%. Their development was highly correlated with the type of lesions at diagnosis (highest risk with abscessual lesions; uni- and multivariate analysis). No other clinical or laboratory marker (age, fever, positive cultures, levels of acute phase reactants, interval between onset and diagnosis) was correlated with the outcome (scars). The type of lesion at diagnosis of acute uncomplicated pyelonephritis is highly correlated with the development of kidney scars. Further studies are needed to test the therapeutic schedules tailored according to the imaging data.

Radiographic and ultrasonographic evaluation of the upper urinary tract diseases in dogs: 22 cases

Summary: The objectives of the present study were to describe the complementary use of radiography and ultrasonography in the diagnosis of upper urinary tract disorders in dogs, and to compare ultrasonographic findings with the survey and contrast radiographic findings in the evaluation of canine upper urinary tract diseases. The study materials were composed of 22 dogs of various breed, age, and sex with upper urinary tract diseases. Pyelonephritis (9 cases), acute renal failure (7 cases), policystic renal disease (2 cases), bilateral hydronephrosis (one case), radiopaque nephrolith (2 cases), unilateral ectopic ureter (one case) were diagnosed radiographically and ultrasonographically. The results of the present study indicate that ultrasonography was more sensitive than radiography in diagnosis of upper urinary diseases but was incapable in qualitative evaluation of renal functions and in examination of the ureters. Survey radiographs had little value in the diagnosis of pyelonephritis, disorders of renal pelvis, ureters except for the identification of radiopaque nephrolith. It was determined that EU was valuable for determination of the ectopic ureter, hydronephrosis, and evaluation of renal function.

Downregulation of the expression of bone morphogenetic protein 7 in experimental pyelonephritis

Bone morphogenetic protein 7 (BMP 7) is a member of the transforming growth factor (TGF) beta superfamily and is involved in regeneration, repair, and development of specific tissues, for example kidney, gut, lens, and skeleton. BMP 7 has emerged as a renotrophic factor and experimental studies have shown its protective role against fibrotic processes. Tubulointerstitial changes are present in the pyelonephritic kidney which progresses to fibrosis. Renal fibrosis may lead to significant morbidity in the form of hypertension, proteinuria, and loss of renal function. The objective of this study was to investigate BMP 7 expression in experimental acute and chronic pyelonephritis models. Eighteen Wistar rats were injected with 0.1 mL solution containing E. coli ATCC 25922 10(10) cfu mL(-1) into left renal medullae. Six rats were used as a sham group and were given 0.1 mL 0.9% NaCl. Pyelonephritic rats were sacrificed 24 h (group I, n=6), 1 week (group II, n=6), and 6 weeks (group III, n=6) after E. coli injection. Serum creatinine levels were analyzed. Renal tissues were studied histopathologically by use of hematoxylin and eosin and scored for diagnosis of pyelonephritis. BMP 7 expression was studied semiquantitatively by immunohistochemical staining. Acute (group I) and chronic (group II and group III) pyelonephritic histopathological changes were observed in experimental pyelonephritic groups. A gradual decrease in BMP 7 expression was observed in the tubulointerstitial and tubular area of the pyelonephritic kidneys, mildest in the acute pyelonephritic group and most severe in the chronic pyelonephritic 6th week group. A statistically significant difference was observed between tubulointerstitial BMP 7 expression by groups I and III (P=0.017) and by groups III and IV (P=0.000). Tubular BMP 7 expression was statistically significantly different between groups II and IV (P=0.009) and between groups III and IV (P=0.002). The data imply that BMP 7 has a major role in chronic pyelonephritis. Tubulointerstitial and tubular BMP 7 expression also had a significant negative correlation with fibrosis, tubular, atrophy, and vascular changes. Serum creatinine levels of the study group were all normal. We conclude that the decrease in renal BMP 7 expression in experimental chronic pyelonephritis is one of the factors responsible for fibrotic changes in persistent renal damage.

Relation of arterial hypertension with kidney in patients before and after removal of pheochromocytoma

Kidney state was studied in 28 patients (pts) before removal of pheochromocytoma (pheo) as well as during one year after operation (Group 1), and in 84 pts in 2-29 years after surgery (Group 2). All pts with pheo (48 m and 64 w, aged 45,1±1,3 year, range 12-70) had hypertension. Before operation patients in Group 1 had nycturia and polyuria (16,6%), proteinuria (91,3%), microhematuria (35%), cylinderuria (39%), decreased glomerular filtration (42%), transient increase of blood creatinine during paroxysms of hypertension (13,3%), increased plasma renin activity (65,2%) and concentation of aldosteron (43,5%). In one case hydronephrosis was related to extraadrenal tumor generating pressure on ureter, and after operation diagnosis of pyelonephritis was made. 3 pts had renal artery stenosis (one case of renal artery pressed by tumor, and two cases of functional renal stenosis veryfied by operation). Marked changes of intrarenal arteries and renal parenchyma because of severe prolonged hypertension (21,5%) and signs of hyperfunction of juxtaglomerular apparatus (26%) were seen by intraoperative kidney biopsy (n=23). After operation there was normalization of kidney functional state in all pts of Group 1. During one year after operation 11 of 112 pts (9,8%) had moderate or severe residual hypertension related to kidney hypertensive arteriolosclerosis. During remote period after removal of pheo 24 pts of group 2 became hypertensive again, but only in 3 pts concomitant kidney diseases were revealed (calculary pyelonephritis, diabetic nephropathy, pathological mobility). 13 pts in Group 2 also had concomitant renal diseases or congenital anomalies but they were normotensive. We can conclude that changes of kidney function in pheo, and especially marked proteinuria, are not signs of kidney organic parenchymal affection. Kidney hypertensive arteriolosclerosis and renal artery stenosises in pheo can make arterial hypertension more severe. Kidney hypertensive arteriolosclerosis can be cause of hypertension soon after removal of pheo, as well as concomitant renal diseases in remote period after operation.

Risk Factors Associated with Acute Pyelonephritis in Healthy Women

Although most cases of acute pyelonephritis occur in otherwise healthy women, data on risk factors for this condition are lacking. To evaluate infection characteristics, incidence, and risk factors associated with acute pyelonephritis in a sample of women. Population-based case-control study. Group Health Cooperative, a prepaid health plan in Washington. 788 nonpregnant women, 18 to 49 years of age. Case-patients (n = 242) were women with pyelonephritis who were identified from computerized databases. Controls were 546 similar-age women with no pyelonephritis diagnosis in the previous 5 years who were randomly selected from enrollment databases. Response rates for case-patients and controls were 73% and 64%, respectively. Characteristics of infection and potential risk factors for pyelonephritis, ascertained through computer-assisted telephone interview and computerized databases. 7% of case-patients were hospitalized. Escherichia coli was the infecting pathogen in 85% of cases. In multivariable models, factors associated with pyelonephritis risk were frequency of sexual intercourse in the previous 30 days (odds ratio, 5.6 [95% CI, 2.8 to 11.0] for > or =3 times per week), recent urinary tract infection (UTI) (odds ratio, 4.4 [CI, 2.8 to 7.1]), diabetes (odds ratio, 4.1 [CI, 1.6 to 10.9]), recent incontinence (odds ratio, 3.9 [CI. 2.6 to 5.9]), new sexual partner in the previous year (odds ratio, 2.2 [CI, 1.4 to 3.6]), recent spermicide use (odds ratio, 1.7 [CI, 1.1 to 2.8]), and UTI history in the participant's mother (odds ratio, 1.6 [CI, 1.1 to 2.5]). Risk factors for selected subgroups (patients < or = 30 years of age, patients > 30 years of age, patients with no UTI history, and inpatients) were also evaluated. Potential recall bias, reliance on automated case definition criteria, and limited data on diabetes and incontinence variables. Few nonpregnant, community-dwelling women younger than 50 years of age with pyelonephritis are hospitalized. As with cystitis in reproductive-age women, sexual behaviors and patient and family history of UTI are associated with increased pyelonephritis risk. Diabetes and incontinence also seem to independently increase the risk for pyelonephritis.

Urine culture susceptibility reports may be misleading: Cultured patients may be different than the majority treated empirically

Study objectives: Hospital antimicrobial susceptibility reports (antibiograms) are recommended for guiding empiric therapy, but guidelines often recommend culturing only patients likely to have resistant or complicated infections. Therefore, antibiograms may not reflect the organisms present in the majority of empirically treated low-risk patients, resulting in accelerated development of antimicrobial resistance in the community. We asked how many emergency department (ED) patients treated for urinary tract infection (UTI) had urine cultures (UCS) performed and what the results were relative to empiric treatment decisions. Our specific hypothesis was that cultured patients would differ clinically from noncultured patients in risk of resistant or complicated infection. Methods: This was a retrospective cross-sectional study. Electronic and clinical records for consecutive adults treated for UTI in an urban public teaching hospital were abstracted for demographic, comorbidity, severity of illness, laboratory test result, UCS, diagnosis, treatment, and disposition data. Cases were identified as any patient older than 17 years and with any discharge or admission diagnosis of UTI or one of its synonyms. Factors known to be associated with resistant infections were measured. In the specific comparisons of clinical factors that might predict either receiving a UCS or having a positive UCS result, statistical significance was tested using Student's t test for continuous and χ 2 analysis for dichotomous variables. The α chosen was 0.001 because 11 factors were examined. Results: Of 685 adult UTI patients identified, 30 (4%) were excluded because of unavailable medical records. There were 655 eligible patients with a mean age of 40 years (SD 17 years), 90 (14%) were men, 133 (20%) were diagnosed with pyelonephritis or sepsis, 124 (19%) had underlying genitourinary comorbidity or devices, 79 (12%) were diabetic, 18 (3%) had cancer, and 52 (8%) had renal stones. There were 216 (33%) patients who received UCS (95% confidence interval [CI] 29% to 37%). Those receiving UCS were significantly older, had higher blood urea nitrogen and creatinine levels, and were more likely to be male and diabetic and to have underlying genitourinary problems ( P P 1%) patients received nitrofurantoin. Choice of antibiotic was not significantly associated with performing UCS or positive UCS. Only 33 (5%) patients were hospitalized or treated in our observation unit. An additional 57 (9%) patients received parenteral antibiotics and fluids in the ED before discharge. Conclusion: Although 55% of patients were discharged on fluoroquinolones, this clinical decision may be based on a hospital antibiogram reflecting a smaller group of patients with higher risk of resistance or adverse outcomes than those empirically treated. Only 33% of our sample received UCS. Those patients had higher rates of comorbidity and severity of illness indicators predictive of resistant infection than those who did not receive UCS. Even so, only 2% of the total sample had a culture-documented requirement for fluoroquinolone treatment. Also, the older, less costly nitrofurantoin had better activity against the recovered organisms than fluoroquinolones did but was used to treat only 4% of patients. Over a 3-year period, our hospital antibiogram has reflected a 10% reduction in the effectiveness of fluoroquinolones in eradicating typical urinary pathogens, which may be due to their excessive use in ambulatory low-risk patients who would benefit from less broad-spectrum agents. Our findings suggest that intermittent surveillance cultures in low-risk UTI patients may promote improved antimicrobial choices and cost savings.

DIAGNOSIS AND TREATMENT OF PRESUMPTIVE PYELONEPHRITIS IN AN ASIAN ELEPHANT (ELEPHAS MAXIMUS)

A 37-yr-old female Asian elephant (Elephas maximus) presented with anorexia, restlessness, and dark-colored urine. Urinalyses showed hematuria, leukocyturia, isosthenuria, proteinuria, granular casts, and no calcium oxalate crystals. Bloodwork revealed azotemia. Urine culture revealed a pure growth of Streptococcus zooepidemicus resistant to sulfamethoxazole-trimethoprim but susceptible to cephalosporins. A presumptive diagnosis of pyelonephritis was made based on bloodwork, urinalysis, and urine culture. The animal was treated with intravenous ceftiofur, and intravenous and per rectum fluids were given for hydration. The elephant's attitude and appetite returned to normal, the abnormal blood parameters resolved, and urinary calcium oxalate crystals reappeared after treatment, supporting presumptive diagnosis. Follow-up ultrasonography revealed an abnormal outline of both kidneys with parenchymal hyperechogenicity and multiple uterine leiomyomas.