Non-febrile Urinary Tract Infection Research Articles

Open distal ureteroureterostomy for non-refluxing duplicated collecting system in children: Multicentric study and mid-term outcomes

When indicated, ureteroceles and ectopic ureters in duplicated collecting systems can be managed via upper or lower urinary tract surgical approaches, or a combination of both. Open ureteroureterostomy (UU) has been described to address these conditions in the absence of lower pole (LP) vesicoureteral reflux (VUR). We report outcomes from multiple centers worldwide with mid-term follow-up. Our study consists of a retrospective review of records and imaging of children who underwent open distal UU via inguinal incision for duplicated collecting system without lower pole VUR in institutions from North America, South America, and the Caribbean. Descriptive statistics and univariate analysis were utilized. The records of 127 patients who underwent open distal UU for double collecting system between 2009 and 2022 were reviewed. Of those, 65% were female (n=82), with a mean age at operation of 18 months (range 3-180). Main presentation at surgery included prenatal hydronephrosis (64%, n=81), followed by febrile urinary tract infections (28%, n=36), and urinary incontinence or other (8%, n=10). The patients with antenatal or incidental diagnosis of hydronephrosis were classified as preoperative Society for Fetal Urology (SFU) grade 3 (n=64) and 4 (n=54) (96%). Those who were classified with SFU grade 0-2 (4%) had symptomatic clinical presentations including febrile urinary tract infections (UTIs) (n=3), urinary incontinence (n=3), and a 12-year-old patient with recurrent abdominal pain (n=1). Mean operative time from skin incision to skin closure was 86min (range 45-240). Mean hospital stay was estimated at 1.1 days (range 0.5-4). In our cohort of 127 patients, 3 (2%) developed Clavien-Dindo grade I (2 with ureteral stent displacement and 1 with a urine leak/managed conservatively), 6 (5%) with grade II (3 febrile and 3 non-febrile UTIs managed with oral antibiotics), and 2 (2%) with grade IIIb complications (urine leaks requiring surgical management), which were appropriately treated. None presented grade IV or V complications. A double J stent was used in 56 patients (44%), and a Penrose drain was left in 10 (8%). A total of 125 children (98%, n=125/127) showed sonographic improvement of hydronephrosis, or resolution of symptoms with stable ultrasound findings. Successful outcome was similar for both ureterocele and ectopic ureter subgroups: 49/49 patients with ureterocele showed 100% improvement, 76/78 children with ectopic ureter showed improvement in 97% of the cases. On univariate analysis, outcomes were similar regardless of the use of ureteral stents (p=0.11). Mean follow-up was 28.2 months (range 12-85). Open distal UU is a good alternative for the definitive surgical management of ectopic ureters and ureteroceles without LP VUR. This multicentric and mid-term follow-up study demonstrates that open distal UU offers high success rates, low morbidity, short operative times and hospital stays, and satisfactory aesthetic outcomes. Additionally, the surgery is performed extra-peritoneally and may not require the use of stents or drains, depending on surgeon preference. Further investigations are being conducted to determine the role of UU in the settings of double collecting systems associated with ipsilateral LP VUR.

Are Positive Urine Cultures Directly Correlated with Elevated Levels of Novel Biomarkers for Childhood Urinary Tract Infection?

Urinary tract infection (UTI) in children is one of the most common bacterial infections that propels inappropriate antibiotic use. Long-term, potentially fatal complications can occur if not properly treated. Prompt investigation and appropriate treatment would prevent these complications. Although urine culture remains the gold standard investigation for UTI, its process is cumbersome and requires time (24–72 hours). Hence, there has been growing interest in the use of urinary biomarkers. However, some conventional urinary biomarkers detected on urinalysis have poor sensitivity values when used singly as a screening tool. Thus, the searchlight has shifted to the role of novel biomarkers in UTI diagnosis. This narrative review aimed to determine if elevated levels of these biomarkers directly correlate with positive urine cultures. A positive correlation may imply that these biomarkers could serve as novel UTI diagnostics and thus augment urine culture requests. Established and recent serum and urinary biomarkers show disparate predictive abilities for UTI and its related complications. Some have elevated differential levels in upper and lower UTI or febrile and non-febrile UTI. All studies that investigated these biomarkers established culture-positive UTI, highlighting a direct correlation between positive urine cultures and increased concentrations of the biomarkers in body fluids. Because certain uropathogens were less likely to be associated with pyuria, the sensitivities of some neutrophil-related novel biomarkers (such as urine neutrophil gelatinase-associated lipocalin and human neutrophil peptides 1–3) were reduced in cases of UTI caused by these bacteria. While levels of these novel biomarkers directly correlate with positive urine cultures, it appears that there is yet no standalone biomarker with the optimal sensitivity and specificity for UTI. Although these novel biomarkers are promising, translating their measurements into clinical practice with specific clinical utilities will take time. Novel methods interrogating high-throughput serum (and urine) metabolome data with positive urine cultures in a platform-agnostic manner (metabolome-wide approach) will help confirm and identify novel biomarkers that might capture specific aetiologic agents or shared pathways of related agents. The authors recommend that future research on UTI diagnostics should specifically focus on identifying highly sensitive and specific standalone novel biomarkers that can be easily applied as a point-of-care investigation.

Indications for operation and results from surgical treatment of vesicoureteral reflux

The main objective of this retrospective study was to evaluate the value of surgical approach in the treatment of children with vesicoureteral reflux (VUR). Material and method: The study was conducted in the period from January 2006 to December 2014, and included children with symptomatic VUR, who were surgically treated. A total of 72 children were treated, of whom 56 were females and 16 were males, aged between 2 and 16 years. They were treated with IV and V grade reflux ureters. Thirty-two of the unilateral refluxes were left-sided, 18 right-sided and 22 both-sided. VUR was diagnosed with Voiding cystourethrography (VCUG). Cohen technique was performed in 64 (90%) patients, Politano-Lead better technique in 4 (5%) patients and Lich-Gregoir technique in 4 (5%) patients. Results: Out of the 72 treated patients, 69 had a postoperative negative finding of VUR on the performed VCUG, indicating a high 95% success rate. In three girls, persistent postoperative reflux was found in postoperative VCUG. In the first patient persistent VUR was unilateral, of V grade. In the second patient, a third-degree VUR was found and the third patient was diagnosed with II grade VUR. Postoperatively, non-febrile UTIs (urinary tract infections) were diagnosed in 23 patients (20 female children and 3 male children) out of 72 patients in total. One female child was hospitalized with febrile UTI and 8 patients or 10% developed febrile UTI within one year of the operative treatment. Conclusion: Open surgery, despite excellent results, is used for more complicated cases, VUR grade IV – V or in previously failed cases, and it does not appear to provide definitive correction of VUR in all patients and does not prevent certain low incidence of UTI postoperatively. Non-febrile UTIs can occur several years after a surgical correction. Endoscopic treatment is an alternative treatment for VUR

Urinary vanin-1 for predicting acute pyelonephritis in young children with urinary tract infection: a pilot study

Background Vanin-1, an epithelial glycosylphosphatidylolinositol (GPI)-anchored pantetheinase, is a valuable marker of renal injury. Purpose The aim of this study was to assess the predictive value of vanin-1 in acute pyelonephritis (APN) in comparison to the conventional serum inflammatory markers in children aged 1–24 months with the first episode of urinary tract infection (UTI). Material and methods Urinary vanin-1, vanin-1/Cr ratio, WBC, CRP, PCT were analysed in 58 children with febrile UTI and in 18 children with non-febrile UTI. Febrile UTI group was divided into APN subgroup (n = 29) and non-APN subgroup (n = 29), based on the results of Tc-99m-ethylenedicysteine scan. Results The mean vanin-1 level was higher in the APN group compared to the non-febrile UTI group (p = 0.02) and did not differ between APN and non-APN subgroup. In univariate analysis, vanin-1 (p = 0.042), CRP (p < 0.001), PCT (p < 0.001), and WBC (p = 0.022), were associated with APN, but only vanin-1 (p = 0.048) and CRP (p = 0.002) were independent markers of APN. In ROC analysis, vanin-1, with its best cut-off value of 16.53 ng/mL, had worse diagnostic profile (AUC 0.629, sensitivity 58,6%, specificity 63.8%) than CRP, PCT and WBC (AUC: 0.937; 0.880; 0.667, respectively). Conclusions Vanin-1 is not useful for predicting APN, since its diagnostic value is inferior to other conventional serum inflammatory markers.

Serum neutrophil gelatinase-associated lipocalin for predicting anemia of inflammation in children with urinary tract infection.

Anemia of inflammation (IA), the second most common cause of childhood anemia, results from macrophage iron sequestration and impaired erythropoiesis. Neutrophil gelatinase-associated lipocalin (NGAL) plays an important role in innate microbial immunity through its influence on intracellular iron homeostasis and inhibition of erythropoiesis. The predictive value of NGAL in IA was assessed in 74 children (age 6.30 ±3.64 months) with the first episode of urinary tract infection (UTI). Anemia of inflammation was found in 50% of children, including those with non-febrile UTI, and delayed onset of anemia was observed in 20% of children. There were no differences in NGAL levels between the anemic and non-anemic children, and no correlations between NGAL and hemoglobin (HGB) levels and red blood cell (RBC) count. In multivariate logistic regression analysis elevated C-reactive protein (CRP) was only independently associated with the presence of anemia in children with UTI [OR (95% CI): 1.128 (1.005-1.265), p = 0.040]. In stepwise multiple analysis age independently correlated with RBC (β = 0.051, p = 0.001), while CRP independently correlated with HGB (β = –0.037, p = 0.027) and RBC (β = –0.022, p = 0.014). ROC analysis demonstrated better diagnostic profiles for CRP, procalcitonin (PCT) and fever duration for predicting the risk of IA than NGAL (AUC: 0.690, 0.669, 0.678 vs. 0.638, respectively). Despite the increase in HGB levels after 4-5 weeks from the onset of UTI, HGB values were still significantly lower in the anemic than in non-anemic children. NGAL was not useful for predicting IA in UTI, since its diagnostic value was inferior to conventional inflammatory markers.

Effect of rectal mucosa cleansing on acute prostatitis during prostate biopsy: A randomized prospective study

Infectious complications after transrectal ultrasound-guided prostate biopsy (TRUS-PB) can range from asymptomatic bacteriuria and febrile or non-febrile urinary tract infection (UTI) to sepsis. Cleaning of rectal mucosa with topical antiseptics such as povidone iodine or chlorhexidine before the procedure are alternative prophylaxis methods. We aimed to investigate the effects of these two different topical antiseptic agents on infectious complications and their superiority to each other. The study was conducted with 200 patients. Rectal mucosa cleansings were performed in 50 patients with povidone iodine and 49 patients with chlorhexidine. The remaining 101 patients did not receive any antiseptic treatment. The results were examined according to the hospital admissions or hospitalization for the first 30 days after the procedure due to UTI, body temperature >38.5°C, sepsis, hematuria, rectal bleeding, and urinary retention. The mean age of study population was 63.3±7.26 years, and the mean prostate specific antigen value was 13.96±29.5 ng/mL. Acute prostatitis occurred in 14 patients (7%), 9 of whom were hospitalized due to sepsis after TRUS-PB. Statistically significant less acute prostatitis was observed in those patients who were treated with topical rectal antisepsis (topical rectal antisepsis 2% vs. no rectal antisepsis 12.1%, p=0.01). Chlorhexidine and povidone iodine were not superior to each other in terms of inhibiting the development of acute prostatitis (chlorhexidine 2% vs. povidone iodine 2%, p=1.00). Rectal mucosal cleansing with chlorhexidine or povidone iodine before TRUS-PB prevented the development of sepsis due to acute prostatitis. We recommend that this effective method, which is easy to apply, cheap, reliable, easily tolerated should be used in all prostate biopsy practice.

Pilot study showed that poor feeding, especially with leucocyturia, increased the odds of non-febrile urinary tract infections in children who were not toilet trained.

This study assessed the prevalence of wrongly diagnosed non-febrile urinary tract infections in patients who had not been toilet trained and presented with poor feeding and, or, failure to thrive. The diagnostic value of these signs in predicting non-febrile UTIs was also explored. We focused on 59 outpatients (56.7% male) with these criteria, who had positive urine cultures and were referred to our Italian University hospital from January 2017 to January 2019. None were on antibiotics and all underwent urine cultures by bladder catheterisation. Wrongly diagnosed non-febrile UTIs were defined by sterile urine cultures. The predictive value was evaluated using logistic regression. The mean age was 8.5±5.7months and 72.9% had wrongly diagnosed non-febrile UTIs. Poor feeding was significantly higher among the 16 patients with true non-febrile UTIs (P=.04). It was significantly predictive of non-febrile UTIs (odds ratio 4.1, 95% confidence interval 1.1-16.6), especially when leucocyturia was present (odds ratio 9.7, 95% confidence interval 2.3-40.7). Wrongly diagnosed non-febrile UTIs were high in children with poor feeding and, or, failure to thrive. Only poor feeding and, in particular, the combination of poor feeding and leucocyturia, significantly increased the odds of non-febrile UTI.

Prognostic value of serum and urine kidney injury molecule-1 in infants with urinary tract infection.

IntroductionKidney injury molecule-1 (KIM-1) is an important diagnostic and prognostic marker in acute kidney injury and chronic kidney disease of various aetiologies. The aim of the study was to evaluate the usefulness of serum KIM-1 (sKIM-1) and urine KIM-1 (uKIM-1) for predicting febrile and non-febrile urinary tract infection (UTI) in infants.Material and methodsA prospective study included 101 children divided into three groups: febrile UTI 49 children, non-febrile UTI 22 children, and healthy controls 30 children. The following laboratory tests were performed: sKIM-1, uKIM-1, white blood count (WBC), C-reactive protein (CRP), and procalcitonin (PCT).ResultsMedian levels of sKIM-1 were significantly higher in the febrile and non-febrile UTI group compared to the healthy controls (both p < 0.05). Mean levels of uKIM-1 were significantly lower in the febrile UTI group compared to the non-febrile UTI group and healthy controls (p < 0.001 and p < 0.0001, respectively). Univariate logistic regression analysis has demonstrated a positive association of sKIM-1 with febrile and non-febrile UTI (both p < 0.05), and negative association uKIM-1 with febrile UTI (p < 0.0001). Receiver operating curve (ROC) analysis showed good diagnostic profiles of uKIM-1 with a best cut-off value of 2.4 ng/ml and sKIM-1 with a best cut-off value of 3.88 ng/ml for predicting febrile UTI (area under the curve [AUC] 0.82 and 0.67, sensitivity 73% and 63%, specificity 86% and 80%, respectively).ConclusionssKIM-1 can be useful for predicting febrile UTI. We do not recommended use of uKIM-1 as a marker of febrile UTI because of its negative association with febrile UTI. Both markers are not useful for predicting non-febrile UTI.

Association of vesicoureteral reflux and renal scarring in urinary tract infections.

The aim was to investigate the relationship between vesicoureteral reflux (VUR) and renal damage in non-febrile, febrile for the first time and recurrent urinary tract infection (UTI) patients. The secondary aim was to determine whether C-reactive protein (CRP) in febrile UTIs could be a predictor of renal scarring. This prospective study included non-febrile, febrile for the first time and recurrent pediatric UTI cases. The routine lab analyses comprised a complete blood count, urea, creatinine, fully automated urinalysis, urine culture and CRP analyses. All the participants were examined using urine ultrasonography subsequent to their UTI diagnosis, voiding cystourethrography (VCUG) after six weeks and Tc-99m dimercaptosuccinic acid (DMSA) static renal scintigraphy after six months. There were included 47 children with non-febrile UTIs, 48 with first febrile UTIs and 61 with recurrent UTIs. A statistically significant difference was found among the groups in terms of VUR and renal scarring (p= 0.001 and p= 0.011, respectively). A statistically significant difference was also found in terms of renal scarring between patients with and without VUR (p= 0.001). Moreover, a statistically significant difference was also present in relation to renal scarring (p <0.05) in patients with five-fold lower or higher CRP values than the accepted cut-off value (5mg/dl). The ratio of renal scars detected was found to be parallel to the VUR frequency. The higher the VUR grade, the more renal damage was found. A positive correlation between elevated CRP and renal scarring was determined, indicating the presence of scarring during the diagnosis of pyelonephritis.

Prevalence of and risk factors for symptomatic urinary tract infection after endoscopic incision for the treatment of ureterocele in children

To clarify the impact of endoscopic incision (EI) for ureterocele as an initial procedure, by performing a retrospective chart review, focusing on the prevalence of and risk factors for symptomatic urinary tract infection (UTI) after EI. In the present study we included children with ureterocele, managed between September 1994 and April 2016, who were observed conservatively without additional surgical management after EI. Ureterocele was categorized as intravesical or ectopic. Symptomatic UTI was defined as either recurrent non-febrile or febrile UTI. The prevalence of and risk factors for symptomatic UTI were analysed using Cox proportional hazard models or Kaplan-Meier curves, and the log-rank test. A total of 36 children met the inclusion criteria. The median age of the participants at EI was 8.9 months. Eleven children had symptomatic UTIs (febrile, n = 9; recurrent non-febrile, n = 2) during the median follow-up of 75.5 months. Initial symptomatic UTI in each child occurred <25 months after EI. The symptomatic UTI-free rate after EI was 65.6%. The risk factors for symptomatic UTI were female gender, duplex system, ectopic ureterocele, and unchanged hydronephrosis after EI. The present study determined the critical period and risk factors for symptomatic UTI after EI for the treatment of ureterocele. The results suggest that when conservative management is indicated after EI, patients, especially those with risk factors, should be followed carefully at least for 25 months after EI for symptomatic UTI.

Triggered Urine Interleukin-6 Correlates to Severity of Symptoms in Nonfebrile Lower Urinary Tract Infections

Objective diagnosis of symptomatic urinary tract infections in patients prone to asymptomatic bacteriuria is compromised by local host responses that are already present and the positive urine culture. We investigated interleukin-6 as a biomarker for nonfebrile urinary tract infection severity and diagnostic thresholds for interleukin-6 and 8, and neutrophils to differentiate between asymptomatic bacteriuria and urinary tract infection. Patients with residual urine and neurogenic bladders due to spinal lesions included in a long-term Escherichia coli 83972 asymptomatic bacteriuria inoculation trial were monitored for 2 years. Symptom scoring and urine sampling to estimate interleukin-6 and 8, and neutrophils were performed regularly monthly and at urinary tract infection episodes. Patients were followed in the complete study for a mean of 19 months (range 10 to 27) and those with asymptomatic bacteriuria with E. coli 83972 were followed a mean of 11 months (range 4 to 19). A total of 37 nonfebrile urinary tract infection episodes with complete data on interleukin-6 and 8, neutrophils and symptom scoring were documented. Interleukin-6 was the only marker that persistently increased during urinary tract infection compared to asymptomatic bacteriuria in pooled and paired intra-individual comparisons (p <0.05). Interleukin-6 above the threshold (greater than 25 ng/l) correlated to more severe urinary tract infection symptoms (p <0.05). The sensitivity and specificity of all biomarkers were poor/moderate when differentiating asymptomatic bacteriuria vs all urinary tract infection episodes. However, in urinary tract infections with worse symptoms interleukin-6 and neutrophils demonstrated equal good/excellent outcomes. Triggered interleukin-6 correlated to urinary tract infection symptom severity and demonstrated a promising differential diagnostic capacity to discriminate urinary tract infection from asymptomatic bacteriuria. Future studies should explore interleukin-6 as a biomarker of urinary tract infection severity and assess the treatment indication in nonfebrile urinary tract infections.

Neutrophil Gelatinase-Associated Lipocalin: A Biomarker for Early Diagnosis of Urinary Tract Infections in Infants.

Early diagnosis of urinary tract infection (UTI) is challenging in infants due to unspecific symptoms, difficulty in urine collection and possible contamination. The aim of this study was to assesses the usefulness of serum and urine neutrophil gelatinase-associated lipocalin (sNGAL and uNGAL, respectively) in the diagnosis of febrile and non-febrile UTI in infants. This prospective observational study enrolled 66 infants with the first episode of UTI and 18 healthy controls. At the time of enrollment, sNGAL, uNGAL, urinalysis, urine culture, white blood cell count (WBC), C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), procalcitonin (PCT), and serum creatinine (sCr) were assessed. We found that, on average, both sNGAL and uNGAL levels were significantly higher in febrile UTI, compared to non-febrile UTI and controls. In turn, the mean sNGAL level, but not uNGAL, was significantly higher in the non-febrile UTI group compared to controls. sNGAL positively correlated with WBC, CRP, ESR and PCT, and uNGAL with CRP and leukocyturia. The receiver operating curves (ROC) demonstrate that the optimum cut-off of 76.2ng/ml for sNGAL (sensitivity 92.9%, specificity 94.4%, and the area under the curve (AUC) of 0.98) and of 42.2ng/ml for uNGAL (sensitivity 73.8%, specificity 72.2%, and AUC of 0.76) for diagnosing febrile UTI and 39.0ng/ml for sNGAL (sensitivity 83.3%, specificity 55.6%, and AUC of 0.70) for diagnosing non-febrile UTI. In conclusion, serum NGAL is an excellent marker for the early diagnosis of febrile UTI, with sensitivity and specificity higher than those of urine NGAL. Diagnostic sensitivity of serum NGAL is smaller in non-febrile infants suffering from UTI, and urine NGAL is not useful for this purpose at all.

The role of voiding cystourethrography in asymptomatic unilateral isolated ureteropelvic junction obstruction: A retrospective study

The presence of concomitant vesicoureteric reflux (VUR) and ureteropelvic junction obstruction (UPJO) is uncommon. Nevertheless, the reported VUR coexisting with asymptomatic unilateral isolated hydronephrosis (AUIH) requiring pyeloplasty for correction of UPJO was of low grade and mostly resolved during conservative follow-up. Therefore, VCUG may be not indicated in these children except if voiding symptoms, urinary tract infection (UTI), dilated ureters, or bladder and ureteric abnormalities are suspected. The aim was to evaluate the need for VCUG in infants <1 year old with AUIH for whom a dismembered pyeloplasty was indicated for correction of UPJO. Ninety-six children <1 year old with pyeloplasty carried out from January 2012 to March 2014 were retrospectively included. Children with voiding symptoms or dilated ureter, duplex system, fused kidneys, bilateral dilatation, or any bladder abnormality on ultrasound were excluded. Anderson-Hynes pyeloplasty was performed through a flank incision. Preoperative VCUG was analyzed in relation to outcome and any UTI during follow-up. The Student t test, Mann-Whitney U test, or Fisher exact test were used to compare variables. Five children had concomitant VUR with UPJO. Most of the children were circumcised during the first postnatal week. The remaining few children were circumcised at the time of pyeloplasty. Side, grade of detected VUR, and complications (18.75%) (postoperative or during follow-up) are presented in the Table. Outcomes in children with and without VUR were not different. Dismembered pyeloplasty was successful in children with VUR and with no complications except for non-febrile UTI in one child only. Ureters were still not dilated at the last follow-up. The required imaging in infants with AUIH is still a subject of debate. As we expected, there was a low incidence of associated VUR in the present study. They were of low grade without any complications during follow-up and without affecting the outcome. The present study has its limitations, including the retrospective nature and short follow-up. However, as at least 2 years of follow-up were documented without any harm or ureteric dilation, VUR will mostly resolve. The present study is strengthened by inclusion of infants only. Our data suggest that VCUG is not indicated in infants with AUIH requiring pyeloplasty for correction of UPJO. VCUG will not affect the treatment decision, operative outcome, or postoperative complications. VCUG may be indicated in case of suspected voiding symptoms, UTI, dilated ureters, or bladder and ureteric abnormalities.

Urinary tract infection pattern in adult women followed from childhood.

The aim of this study was to describe the pattern of urinary tract infection (UTI) and bladder function in women who had experienced recurrent UTI in childhood, with and without consequent renal damage, and followed for three to four decades. A population-based cohort of women who had been followed from the first UTI in childhood and previously studied at a median age of 27 years was studied at a median age of 41years. Renal damage was evaluated by (99m)Tc-dimercaptosuccinic acid scan. Clinical data were collected on the pattern of recurrent UTIs and bladder function. A total of 86 women were investigated, of whom 58 had suffered renal damage and 28 were without. Febrile UTI in adulthood had occurred in 22 patients, once in 15 women and twice or more in seven women. There was a change in the infection pattern over time, evident already in childhood, that was characterized by a decrease in UTI frequency and a shift from febrile to non-febrile infections. A significant association was found between renal damage and febrile UTI (p = 0.046), and between abnormal bladder function and recurrent non-febrile UTI (p = 0.002). There was no relationship between persisting vesicoureteral reflux (VUR) and proneness to either symptomatic UTI (p = 0.99) or febrile UTI in adulthood (p = 0.14). Among this study cohort there was a continuously decreasing rate of febrile UTI in adulthood. Persisting VUR was not related to UTI in adulthood. Abnormal bladder function was related to non-febrile UTI but not to febrile UTI.

Association of O-Antigen Serotype with the Magnitude of Initial Systemic Cytokine Responses and Persistence in the Urinary Tract.

Urinary tract infection (UTI) is one of the most common ailments requiring both short-term and prophylactic antibiotic therapies. Progression of infection from the bladder to the kidney is associated with more severe clinical symptoms (e.g., fever and vomiting) as well as with dangerous disease sequelae (e.g., renal scaring and sepsis). Host-pathogen interactions that promote bacterial ascent to the kidney are not completely understood. Prior studies indicate that the magnitude of proinflammatory cytokine elicitation in vitro by clinical isolates of uropathogenic Escherichia coli (UPEC) inversely correlates with the severity of clinical disease. Therefore, we hypothesize that the magnitude of initial proinflammatory responses during infection defines the course and severity of disease. Clinical UPEC isolates obtained from patients with a nonfebrile UTI elicited high systemic proinflammatory responses early during experimental UTI in a murine model and were attenuated in bladder and kidney persistence. Conversely, UPEC isolates obtained from patients with febrile UTI elicited low systemic proinflammatory responses early during experimental UTI and exhibited prolonged persistence in the bladder and kidney. Soluble factors in the supernatant from saturated cultures as well as the lipopolysaccharide (LPS) serotype correlated with the magnitude of proinflammatory responses in vitro. Our data suggest that the structure of the O-antigen sugar moiety of the LPS may determine the strength of cytokine induction by epithelial cells. Moreover, the course and severity of disease appear to be the consequence of the magnitude of initial cytokines produced by the bladder epithelium during infection. The specific host-pathogen interactions that determine the extent and course of disease are not completely understood. Our studies demonstrate that modest changes in the magnitude of cytokine production observed using in vitro models of infection translate into significant ramifications for bacterial persistence and disease severity. While many studies have demonstrated that modifications of the LPS lipid A moiety modulate the extent of Toll-like receptor 4 (TLR4) activation, our studies implicate the O-antigen sugar moiety as another potential rheostat for the modulation of proinflammatory cytokine production.

Urine interleukin-6, interleukin-8 and transforming growth factor β1 in infants with urinary tract infection and asymptomatic bacteriuria.

IntroductionUrinary tract infection (UTI) occurs in 1.1% of girls and 1.4% of boys during the first year of life. Asymptomatic bacteriuria (ABU) is usually detected incidentally in 0.9% of girls and 2.5% of boys at this age. The aim of the study was to assess the usefulness of measurement of pro-inflammatory urine interleukin (IL)-6 and IL-8 concentrations and anti-inflammatory transforming growth factor β1 (TGF-β1) level in infants with febrile UTI, non-febrile UTI and ABU.Material and methodsA total of 35 children, mean age 6.14 ±3.47 months, were divided into three groups: group I – febrile UTI (n = 13), group II – non-febrile UTI (n = 13) and group III – ABU (n = 9). At the time of enrollment urine IL-6, IL-8, TGF-β1 and serum C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), and white blood cell count (WBC) were measured. Renal ultrasound was performed in all children, 99mTc-dimercaptosuccinic acid scintigraphy (DMSA) and voiding cystourethrography in children with UTI.ResultsUrine concentrations of IL-6 and IL-8 were significantly higher in febrile UTI compared to those with non-febrile UTI and ABU (p < 0.5, p < 0.01) and positively correlated with CRP, ESR and WBC (p < 0.01). Urine levels of TGF-β1 were significantly higher in children with febrile UTI compared to those with ABU (p < 0.05) and positively correlated with WBC (p < 0.01). Inflammatory changes in the DMSA scan were detected in 66.6% of children with UTI. No significant difference in frequency of an abnormal DMSA scan compared to a normal scan was found in groups with febrile and non-febrile UTI. No relations between urine cytokines, systemic inflammatory markers and changes in DMSA scan were observed. The cutoff value for detection of inflammatory changes in the DMSA scan for IL-8 was 120 pg/mg creatinine (Cr) and 40 pg/mg Cr for TGF-β1. Based on this value, the sensitivity for IL-8 was 58.3%, specificity 100% and for TGF-β1 66.7% and 83.7%, respectively.ConclusionsWe found significant differences in children with febrile UTI and ABU regarding urine IL-6, IL-8 and TGF-β1 levels. Urine cytokines and systemic inflammatory markers do not differentiate between upper and lower UTI in infants.

Incidence of Post-Ureteric Reimplantation Urinary Tract Infection in Primary Vesicoureteral Reflux

Normal 0 false false false MicrosoftInternetExplorer4 Background: The goal of treatment in vesicoureteral reflux (VUR) is to reduce the risk of reflux-associated pyelonephritis. Medical versus surgical treatment for VUR is still controversial, with surgery successful in majority of cases. There are not enough data available in literature on long-term incidence of urinary tract infection (UTI) after reimplantation. The aim of the study was to determine the long-term outcome after reimplantation with respect to UTI, renal scarring and potential risk factors for post-reimplant UTI. Methods: It is a retrospective review of 106 consecutive cases who underwent reimplantation for primary VUR. Results: Incidence of post-reimplant UTI is 12.8%. Majority of our patients were females and showed high grade reflux. Median age at surgery was 32 months. Thirteen patients had post-reimplant UTI. Of this, 12/13 were females, 12/13 had pre-reimplant febrile UTI, 10/13 had high grade VUR, 7/13 had urge incontinence and dysfunctional voiding, and 3/13 had constipation. Only two patients showed new scarring/worsening scarring. Conclusions: It is an established fact that ureteric reimplantation is effective in preventing UTI. Some continue to develop UTI even after successful correction of VUR and it is unclear as to why it happens. Various rates of post-reimplant UTI have been quoted in literature with non-febrile UTI of 40% and febrile UTI of 14%. In our study, febrile UTI rate was 4.9% and non-febrile UTI rate was 7.9%. Post-reimplant UTI resulting in new renal scars is rare. There are some possible risk factors for recurrent UTI after reimplantation, but unfortunately only few of them are reversible (bowel bladder dysfunction). Reimplantation for VUR is a very effective treatment. Incidence of post-reimplant UTI is 12.8% with development of new scars after such UTI is rare. Several risk factors contribute to such UTI. World J Nephrol Urol. 2016;5(1):1-3 doi: http://dx.doi.org/10.14740/wjnu237w

Appropriate antibiotic use for patients with complicated urinary tract infections in 38 Dutch Hospital Departments: a retrospective study of variation and determinants.

BackgroundAppropriate antibiotic use in patients with complicated urinary tract infections can be measured by a valid set of nine quality indicators (QIs). We evaluated the performance of these QIs in a national setting and investigated which determinants influenced appropriate antibiotic use. For the latter, we distinguished patient, department and hospital characteristics, including organizational interventions aimed at improving the quality of antibiotic use (antibiotic stewardship elements).MethodsA retrospective, observational multicentre study included 1964 patients (58 % male sex) with a complicated urinary tract infection treated at Internal Medicine and Urology departments of 19 Dutch university and non-university hospitals. Data of 50 patients per department were extracted from medical charts. QI performance scores were calculated using previously constructed algorithms. Department and hospital characteristics were collected using questionnaires filled in by an internal medicine physician and an urologist. Regression analysis was performed to identify determinants of QI performance. Clustering at department and hospital level was taken into account through inclusion of random effects in a multi-level model.ResultsMedian QI performance of departments varied between 31 % (‘Treat urinary tract infection in men according to local guideline’) and 77 % (‘Perform urine culture’). The patient characteristics non-febrile urinary tract infection, female sex and presence of a urinary catheter were negatively associated with performance on many QIs. The presence of an infectious diseases physician and an antibiotic formulary were positively associated with ‘Prescribe empirical therapy according to guideline’. No other department or hospital characteristics, including stewardship elements, were consistently associated with better QI performance.ConclusionsA large inter-department variation was demonstrated in the appropriateness of antibiotic use. In particular certain patient characteristics (more than department or hospital characteristics) influenced the quality of antibiotic use. Some, but not all antibiotic stewardship elements did translate into better QI performance.Electronic supplementary materialThe online version of this article (doi:10.1186/s12879-015-1257-5) contains supplementary material, which is available to authorized users.

Statin Use and Risk of Sepsis After Percutaneous Nephrolithotomy.

To examine the association between statin medication use and sepsis risk after percutaneous nephrolithotomy (PCNL). Using medical claims data, we identified working-age adults with urinary stone disease who were treated with PCNL. Among this cohort, we determined which patients had a prescription fill for a statin agent that encompassed their surgery date. We then fitted logistic regression models to examine for differences in rates of postoperative sepsis between statin users and nonusers. In addition, we evaluated the frequency of nonfebrile urinary tract infections (UTIs) and intensive care unit (ICU) services utilization and hospital length of stay (LOS) as a function of statin use. During the study period, at total of 2046 patients underwent PCNL, 382 (18.7%) of whom had a prescription fill for a statin agent preceding their surgery. The overall rate of sepsis in this population was 3.8%. After adjusting for patient health status and sociodemographic factors, the rate of postoperative sepsis was comparable between statin users and nonusers (5.3% vs 3.5%, respectively; P=0.105). In addition, UTI and ICU utilization rates did not relate to statin use (P>0.05 for all associations). Adjusted hospital LOS was shorter among statin users, but the difference was clinically trivial (3.6 vs 4.1 days; P=0.007). Statin use is not associated with reductions in postoperative sepsis, nonfebrile UTIs, ICU utilization, or hospital LOS after PCNL. To increase the safety of PCNL, urologists will have to consider other processes of care (e.g., clinical care pathways).

External extension of double-J ureteral stent during pyeloplasty: inexpensive stent and non-cystoscopic removal

The purpose of the study is to describe our experience with the application of externalized double-J ureteral stent (DJUS) during pyeloplasty for correction of ureteropelvic junction obstruction (UPJO) in order to avoid cystoscopy for stent removal. Pyeloplasty was performed in 523 infants with UPJO using miniature pyeloplasty technique. After removing the obstructed segment, a 3-Fr. DJUS was placed into the ureter. In order to avoid cystoscopy for the removal of the stent, a feeding tube was passed through the skin and renal pelvis via a separate stab incision, connected to the DJUS and secured to the external body surface (skin), and the pyeloplasty was completed. The feeding tube along with the stent was removed after 3-4 weeks, respectively. Postoperative follow-up visits were performed 1, 3, and 6 months after the procedure. The mean operative time was 49 min (range 41-79). Patients were discharged after 17 ± 2 h (mean ± SD). No patient experienced bladder spasm or anticholinergic administration. Forty-four patients (8.4 %) experienced minor complications including non-febrile urinary tract infections and mild hematuria. No major complication including urinoma, leakage, and stent migration or displacement was observed during the follow-up period. Stent removal was tolerated by 99.8 % of patients in an outpatient setting with minimal discomfort without performing cystoscopy. Using external DJUS along with a pyelocutaneous stent extension during pyeloplasty is a safe, feasible, and beneficial technique. This technique resulted in high success rate with minimal cost and no renal injury. The non-cystoscopic stent removal and elimination of urethral catheterization following pyeloplasty are the other advantages of this technique.