Presumed Urinary Tract Infection Research Articles

Bacterial meningitis in febrile young infants acutely assessed for presumed urinary tract infection: a systematic review.

Urinary tract infections, the most common severe bacterial infections in young infants, may be associated with co-existing meningitis. There is no consensus on when to perform a lumbar puncture in these infants. Our aim was to quantify the frequency of co-existing bacterial meningitis in febrile young infants acutely assessed for presumed urinary tract infections. We systematically reviewed PubMed, EMBASE, and the Cochrane Library for studies including infants ≤ 3months with suspected/confirmed urinary tract infections, who underwent a lumbar puncture. Two investigators independently reviewed articles for inclusion and extracted relevant data. Our outcomes were culture-confirmed meningitis and identification of low-/high-risk criteria of meningitis. Overall 20/2079 studies, including 4191 infants, met inclusion criteria. A total of 11 infants had bacterial meningitis (frequency between 0 and 2.1% across studies) and were mostly neonates. Of 253 infants meeting the low-risk criteria (well-appearing, age > 21days, procalcitonin ≤ 0.5ng/ml, and C reactive protein ≤ 20mg/L) none developed meningitis, but only 15 underwent lumbar puncture.Conclusion: Co-existing bacterial meningitis in febrile young infants with urinary tract infection is rare. In those meeting low-risk criteria, a lumbar puncture may not be indicated. A case by case assessment should be made in infants not meeting low-risk criteria.Trial registration: CRD42018105339 What is known: • When caring for febrile infants ≤ 3months with urinary tract infections, clinicians may have uncertainty on whether to perform a lumbar puncture (LP) for possible co-existing meningitis What is new: • An up-to-date systematic review of 20 studies found the frequency of co-existing meningitis in this population to be between 0 and 2.1% • Despite limited data, an LP may not be indicated in infants meeting low-risk criteria (being well-appearing, age > 21days, procalcitonin ≤ 0.5ng/ml, C reactive protein ≤ 20 mg/L). Ill-appearance and neonatal age appear to be significant risk factors of co-existing meningitis.

The Urine-culturing Cascade: Variation in Nursing Home Urine Culturing and Association With Antibiotic Use and Clostridiodes difficile Infection

Rates of antibiotic use vary widely across nursing homes and cannot be explained by resident characteristics. Antibiotic prescribing for a presumed urinary tract infection is often preceded by inappropriate urine culturing. We examined nursing home urine-culturing practices and their association with antibiotic use. We conducted a longitudinal, multilevel, retrospective cohort study based on quarterly nursing home assessments between April 2014 and January 2017 in 591 nursing homes and covering >90% of nursing home residents in Ontario, Canada. Nursing home urine culturing was measured as the proportion of residents with a urine culture in the prior 14 days. Outcomes included receipt of any systemic antibiotic and any urinary antibiotic (eg, nitrofurantoin, trimethoprim/sulfonamides, ciprofloxacin) in the 30 days after the assessment and Clostridiodes difficile infection in the 90 days after the assessment. Adjusted Poisson regression models accounted for 14 resident covariates. A total of 131 218 residents in 591 nursing homes were included; 7.9% of resident assessments had a urine culture in the prior 14 days; this proportion was highly variable across the 591 nursing homes (10th percentile = 3.4%, 90th percentile = 14.3%). Before and after adjusting for 14 resident characteristics, nursing home urine culturing predicted total antibiotic use (adjusted risk ratio [RR] per doubling of urine culturing, 1.21; 95% confidence interval [CI], 1.18-1.23), urinary antibiotic use (RR, 1.33; 95% CI, 1.28-1.38), and C. difficile infection (incidence rate ratio, 1.18; 95% CI, 1.07-1.31). Nursing homes have highly divergent urine culturing rates; this variability is associated with higher antibiotic use and rates of C. difficile infection.

Black Esophagus: Rare and Deadly

Acute esophageal necrosis (AEN), also known as ‘black esophagus’ or ‘necrotizing esophagitis’, is a lifethreatening condition which causes diffuse circumferential black appearance of the distal esophagus. This condition is often seen in the critically ill and may be attributed to a vascular watershed area in the distal esophagus. The incidence of AEN varies in endoscopic series from 0.01 to 0.28%, thus signifying a very rare condition. A 73-year-old male with a past medical history of Stage IIIC rectal adenocarcinoma status post low anterior resection and diverting ileostomy presented with intractable nausea, vomiting and malaise. On admission, vitals showed blood pressure of 160/110 and heart rate of 110. Physical examination revealed epigastric abdominal tenderness with no peritoneal signs. Given mild leukocytosis of 11,000 and positive urinalysis patient was started on empiric antibiotics for presumed urinary tract infection. During the hospital course, patient developed acute change in mental status with 1300 milliliters of melenic ostomy output. Repeat vitals showed persistent hypertension and tachycardia with bloodwork showing hemoglobin drop of 2 grams from 14g to 12g with concomitant elevation of BUN to 100. Patient was started on intravenous protonix drip and taken for emergent upper endoscopy which showed diffuse severe mucosal changes characterized by circumferential mucosal necrosis in the entire esophagus extending from 15 cm from the incisors to the gastro-esophageal junction. Exam also revealed gastric erosions and multiple duodenal ulcers. Given the esophageal findings, patient was referred to cardiothoracic surgery for evaluation. Initial plan was to pursue an emergent esophagectomy however patient's family requested hospice care given the overall poor prognosis. Acute esophageal necrosis is associated with several comorbidities including multiorgan dysfunction, persistent hypoperfusion to internal organs, severe vasculopathies, sepsis, gastric volvulus, alcohol abuse or neoplastic diseases. The most frequent clinical presentation is melena, hematemesis, chest pain or dysphagia. Treatment is mainly supportive to maximize organ perfusion, optimize acid suppression and treat any underlying sepsis. Early surgical intervention may be required in cases of perforation, abscess or extent of injury. Clinicians should be aware of AEN in order to appropriately diagnose and manage the disease entity.1838 Figure 1. Diffuse severe mucosal changes seen in the lower third of the esophagus on EGD

The Prevalence of Bacterial Meningitis in Febrile Infants 29-60 Days With Positive Urinalysis.

This study evaluates whether bacterial meningitis prevalence differs by urinalysis result and whether antibiotic treatment of presumed urinary tract infection without cerebrospinal fluid (CSF) culture produces adverse sequelae in febrile infants 29 to 60 days old. This retrospective cohort study identified febrile infants 29 to 60 days old presenting to Kaiser Permanente Northern California sites from 2007 to 2015 who underwent urinalysis and blood, urine, and CSF cultures, comparing the prevalence of meningitis among infants with positive versus negative urinalysis results using a two 1-sided test for equivalence. Additionally, febrile infants treated with antibiotics for positive urinalysis results without CSF culture were identified and their charts were reviewed for adverse sequelae. Full evaluation was performed in 833 febrile infants (835 episodes). Three of 337 infants with positive urinalysis (0.9%; 95% confidence interval [CI]: 0.0%-1.9%) and 5 of 498 infants with negative urinalysis (1%; 95% CI: 0.1%-1.9%) had meningitis. These proportions were statistically equivalent within 1%, using two 1-sided test with a P value of .04. There were 341 febrile infants (345 episodes) with positive urinalysis treated with antibiotics without lumbar puncture. Zero cases of missed bacterial meningitis were identified (95% CI: 0%-1.1%). Zero cases of severe sequelae (sepsis, seizure, neurologic deficit, intubation, PICU admission, death) were identified (95% CI: 0%-1.1%). The prevalence of bacterial meningitis does not differ by urinalysis in febrile infants 29 to 60 days old. Antibiotic treatment of infants with positive results for urinalysis without lumbar puncture may be safe in selected cases.

High Prevalence of Sterile Pyuria in the Setting of Sexually Transmitted Infection in Women Presenting to an Emergency Department.

IntroductionThe clinical presentations for sexually transmitted infections (STI) and urinary tract infections (UTI) often overlap, and symptoms of dysuria and urinary frequency/urgency occur with both STIs and UTIs. Abnormal urinalysis (UA) findings and pyuria are common in both UTIs and STIs, and confirmatory urine cultures are not available to emergency clinicians to aid in decision-making regarding prescribing antibiotics for UTIs. The objective of this study was to determine the frequency of sterile pyuria in women with confirmed STIs, as well as whether the absolute number of leukocytes on microscopy or nitrite on urine dipstick correlated with positive urine cultures in patients with confirmed STIs. We also sought to determine how many patients with STIs were inappropriately prescribed a UTI antibiotic.MethodsWe performed a retrospective chart review of patients aged 18–50 who had a urinalysis and pelvic examination in the emergency department (including cervical cultures), and tested positive for Neisseria gonorrhoeae, Chlamydia trachomatis, and/or Trichomonas vaginalis. Descriptive statistics were obtained for all variables, and associations between various findings were sought using the Fisher’s exact test for categorical variables. We calculated comparison of proportions using the N-1 chi-squared analysis.ResultsA total of 1,052 female patients tested positive for Neisseria gonorrhoeae, Chlamydia trachomatis, and/or Trichomonas vaginalis and were entered into the database. The prevalence of pyuria in all cases was 394/1,052, 37% (95% confidence interval [CI] [0.34–0.40]). Of the cases with pyuria, 293/394, 74% (95% CI [0.70–0.78]) had sterile pyuria with negative urine cultures. The prevalence of positive urine cultures in our study population was 101/1,052, 9.6% (95% CI [0.08–0.11]). Culture positive urines had a mean of 34 leukocytes per high-power field, and culture negative urines had a mean of 24 leukocytes per high-power field, with a difference of 10, (95% CI [3.46–16.15]), which was statistically significant (p=0.003). Only 123 cases tested positive for nitrite on the urinalysis dipstick; 50/123, 41% (95% CI [0.32–0.49]) had positive urine cultures, and 73/123, 59% (95% CI [0.51–0.68]) had negative urine cultures. Nitrite-positive urines were actually 18% more likely to be associated with negative urine cultures in the setting of positive STI cases, (95% CI [4.95–30.42], p=0.0048). Antibiotics were prescribed for 295 patients with suspected UTI. Of these, 195/295, 66% (95% CI [0.61–0.71]) had negative urine cultures, and 100/295, 34% (0.33, 95% CI [0.28–0.39]) had positive urine cultures. Chi-square analysis yielded a difference of these proportions of 32% (95% CI [23.92–39.62], p<0.0001).ConclusionThis study demonstrated that in female patients with STIs who have pyuria, there is a high prevalence of sterile pyuria. Our results suggest that reliance on pyuria or positive nitrite for the decision to add antimicrobial therapy empirically for a presumed urinary tract infection in cases in which an STI is confirmed or highly suspected is likely to result in substantial over-treatment.

Urinary tract infection surveillance in residential aged care

The aim of this research was to determine the prevalence of urinary tract infections (UTIs) in 2 aged care homes (ACHs) and examine the extent to which presumed UTIs met the 2012 McGeer infection surveillance definitions. Retrospective observational study. Two ACHs: a 30-bed facility and a 100-bed facility PARTICIPANTS: Residents of the 2 ACHs diagnosed with UTI. A retrospective review was conducted of UTIs clinically diagnosed at the 2 facilities over a 16-month period, utilizing surveillance and microbiologic data, resident progress notes, and medication charts. This data was reviewed to determine how many diagnosed UTIs met the revised McGeer definitions. Overall, 119 UTIs were diagnosed in 57 residents over 16 months. Only 7 of the diagnosed UTIs met the McGeer definitions. Forty-seven did not meet the clinical evidence, 17 did not meet the microbiologic evidence, and 48 did not meet either surveillance criteria. This study demonstrated the disparity between the clinical diagnosis of UTI and the surveillance definitions for UTI, and highlights the limitations of the McGeer definitions in those with cognitive or communication deficits. There is an urgent need for antimicrobial stewardship programs and education in the ACH setting.

ANTIBIOTIC STEWARDSHIP IN LONG-TERM CARE: RESULTS FROM AN IMPLEMENTATION STUDY

Due to growing concern that unnecessary overuse of antibiotics in nursing homes (NHs) fosters the emergence and dissemination of antibiotic-resistant bacteria, U.S. NHs are being encouraged to establish antibiotic stewardship programs. Unfortunately, successful implementation of such programs is not straightforward, because decision-making involves a complex interplay of factors. Having demonstrated in a clinical trial that antibiotic prescribing can be reduced by over 25% through comprehensive antibiotic stewardship efforts, our research team implemented a dissemination research study in 28 typical community-based NHs to determine change in prescribing and the factors most critical to success in antibiotic stewardship. After one year of implementation, antibiotic prescribing decreased from 12.39 to 10.95 prescriptions/resident day, with most decrease evident for presumed urinary and respiratory tract infections. The session will also discuss the role of nursing home administration, medical staff leadership, staff and provider attitudes, and intervention activities in achieving and maintaining changes in antibiotic prescribing.

Current practice of antibiotic utilization for renal colic in the emergency room.

ABSTRACTIntroduction Urinalysis (UA) in the emergency setting for patients with nephrolithiasis produces potentially confusing results leading to treatment of presumed urinary tract infections (UTIs). Our objective was to evaluate the use of antibiotics in patients with nephrolithiasis in a large network of emergency departments (EDs).Methods A retrospective analysis of all ED visits associated with an ICD-9 diagnosis of nephrolithiasis and a CT scan between 2010 and 2013 was performed. Urinalysis data, the use of IV and PO antibiotics during the ED visit and at discharge were assessed. The presence of fever, elevated serum WBCs, >5 WBCs per hpf, and/or dip positive nitrites were used as appropriate criteria for antibiotic use.Results Urinalysis data were available for 3,518 (70%) of 5,035 patients with an ED diagnosis of nephrolithiasis and CT imaging. Of these visits, 237 patients had positive nitrites (6.7%) and 864 had >5 WBCs per hpf (24.6%) with 158 (4.5%) having both findings for a total of 943 patients. Intravenous antibiotics were given to 244 patients (25.9%) and oral antibiotics were given to 629 patients (66.7 %) with positive UA findings. Of the 2,440 patients with a negative UA and no leukocytosis or fever, 86 patients (3.5%) received IV antibiotics and 533 patients (21.8%) received PO antibiotics upon discharge.Conclusions Proper treatment of nephrolithiasis in the ED includes the screening and diagnosis of concomitant UTIs. However, correct interpretation of UA studies is vital to the correct implementation of antibiotic therapy. This study suggests that 1/3 of patients were undertreated and 21.8% were over-treated.

Urine Culture Follow-up and Antimicrobial Stewardship in a Pediatric Urgent Care Network.

Empiric antibiotic therapy for presumed urinary tract infection (UTI) leads to unnecessary antibiotic exposure in many children whose urine culture results fail to confirm the diagnosis. The objective of this quality improvement study was to improve follow-up management of negative urine culture results in the off-campus urgent care network of Nationwide Children's Hospital to reduce inappropriate antibiotic exposure in children. A multidisciplinary task force developed and implemented a protocol for routine nurse and clinician follow-up of urine culture results, discontinuation of unnecessary antibiotics, and documentation in the electronic medical record. Monthly antibiotic discontinuation rates were tracked in empirically treated patients with negative urine culture results from July 2013 through December 2015. Statistical process control methods were used to track improvement over time. Fourteen-day return visits for UTIs were monitored as a balancing measure. During the study period, 910 patients received empiric antibiotic therapy for UTIs but had a negative urine culture result. The antibiotic discontinuation rate increased from 4% to 84%, avoiding 3429 (40%) of 8648 antibiotic days prescribed. Among patients with discontinued antibiotics, none was diagnosed with a UTI within 14 days of the initial urgent care encounter. Implementation of a standard protocol for urine culture follow-up and discontinuation of unnecessary antibiotics was both effective and safe in a high-volume pediatric urgent care network. Urine culture follow-up management is an essential opportunity for improved antimicrobial stewardship in the outpatient setting that will affect many patients by avoiding a substantial number of antibiotic days.

The Antibiotic Prescribing Pathway for Presumed Urinary Tract Infections in Nursing Home Residents.

Due to the high rates of inappropriate antibiotic prescribing for presumed urinary tract infections (UTIs) in nursing home (NH) residents, we sought to examine the antibiotic prescribing pathway and the extent to which it agrees with the Loeb criteria; findings can suggest strategies for antibiotic stewardship. Chartreview of 260 randomly-selected cases from 247 NH residents treated with an antibiotic for a presumed UTI in 31 NHs in North Carolina. We examined the prescribing pathway from presenting illness, to the prescribing event, illness work-up and subsequent clinical events including emergency department use, hospitalization, and death. Analyses described the decision-making processes and outcomes and compared decisions made with Loeb criteria for initiation of antibiotics. Of 260 cases, 60% had documented signs/symptoms of the presenting illness and 15% met the Loeb criteria. Acute mental status change was the most commonly documented sign/symptom (24%). NH providers (81%) were the most common prescribers and ciprofloxacin (32%) was the most commonly prescribed antibiotic. Fourteen percent of presumed UTI cases included a white blood cell count, 71% included a urinalysis, and 72% had a urine culture. Seventy-five percent of cultures grew at least one organism with ≥100,000 colony-forming units/milliliter and 12% grew multi-drug resistant organisms; 28% of antibiotics were prescribed for more than 7days, and 7% of cases had a subsequent death, emergency department visit, or hospitalization within 7days. Non-specific signs/symptoms appeared to influence prescribing more often than urinary tract-specific signs/symptoms. Prescribers rarely stopped antibiotics, and a minority prescribed for overly long periods. Providers may need additional support to guide the decision-making process to reduce antibiotic overuse and antibiotic resistance.

A Systems Approach to Antimicrobial Stewardship in Pediatric Urgent Care

In urgent or emergency care settings, antibiotics are often prescribed to children for presumed urinary tract infection (UTI) prior to receipt of the

Screening Patients Undergoing Total Hip or Knee Arthroplasty with Perioperative Urinalysis and the Effect of a Practice Change on Antimicrobial Use.

OBJECTIVE To identify predictors of treatment for urinary tract infections (UTI) among patients undergoing total hip (THA) or knee (TKA) arthroplasties and to assess an intervention based on these predictors. DESIGN We conducted a retrospective cohort study of 200 consecutive patients undergoing THA/TKA between February 21, 2011, and June 30, 2011, to identify predictors of treatment for UTI and a prospective cohort study of 50 patients undergoing these procedures between May 21, 2012, and July 17, 2012, to assess the association of signs or symptoms and UTI treatment. We then conducted a before-and-after study to assess whether implementing an intervention affected the frequency of treatment for UTI before or after THA/TKA. SETTING The orthopedics department of a university health center. PATIENTS Patients undergoing THA or TKA. INTERVENTION Surgeons revised their UTI screening and treatment practices. RESULTS Positive leukocyte esterase (P5 (P=.01; P=.01) were associated with preoperative or postoperative UTI treatment. In the prospective study, 12 patients (24%) had signs and symptoms consistent with UTI. The number of patients treated for presumed UTI decreased 80.2% after the surgeons changed their practices, and surgical site infection (SSI) rates, including prosthetic joint infections (PJIs), did not increase. CONCLUSIONS Urine leukocyte esterase and white blood cell count were the strongest predictors of treatment for UTI before or after THA/TKA. The intervention was associated with a significant decrease in treatment for UTI, and SSI/PJI rates did not increase. Infect Control Hosp Epidemiol 2017;38:281-286.

Urinary Tract Infection and Antimicrobial Stewardship in the Emergency Department.

The aims of this study were to assess empiric antibiotic use for presumed urinary tract infection (UTI) in the emergency department (ED) and to determine how often urine culture results subsequently do not confirm the diagnosis. This study is a retrospective cohort study of patients aged 21 years or younger in the Nationwide Children's Hospital ED from May 1, 2012, to October 31, 2012, who had a urinalysis and urine culture performed and were discharged home with empiric antibiotic therapy for presumed UTI. Patients with known urinary tract anomaly or antibiotic use in the previous 7 days were excluded. Confirmed UTI was defined as pyuria (>5 white blood cells per high-power field or dipstick positive for leukocyte esterase) and a positive urine culture (≥50,000 colony-forming units/mL of a uropathogen). Of the 175 enrolled patients, urine was obtained by clean catch in 138 (79%), catheterization in 35 (20%), first-pass void in 1 (0.6%), and undocumented method in 1 (0.6%). Pyuria was demonstrated in 164 patients (94%), but only 97 (55%) had a positive urine culture. The combination of pyuria and a positive urine culture confirmed UTI in 90 patients (51%). The most commonly prescribed antibiotics were cefdinir in 103 patients (59%), trimethoprim/sulfamethoxazole in 40 (23%), and ciprofloxacin in 23 (13%). The median duration of prescribed therapy was 10 days (interquartile range, 7-10 days). Treatment duration was correlated negatively with age (r = -0.53, P < 0.01). The current management of suspected UTI in ED patients results in unnecessary antibiotic exposure, highlighting an important opportunity for outpatient antimicrobial stewardship efforts.

Index of suspicion.

We invite readers to contribute case presentations and discussions. Please use the Submit and Track My Manuscript link on the Pediatrics in Review homepage: http://pedsinreview.aappublications.org . An 11-month-old previously healthy girl is admitted for persistent fevers and loose watery stools of 2 weeks’ duration. She continues to have normal oral intake and urine output. She was evaluated in the emergency department a week earlier for generalized maculopapular rash. A urinalysis revealed 2 to 5 white blood cells (WBCs) per high-power field with few bacteria, and she was treated for a presumed urinary tract infection (her urine culture result was negative for infection after 72 hours). Later, she was seen by her pediatrician, who was concerned about an atypical presentation of Kawasaki disease. She was therefore treated with one dose of intravenous immunoglobulin (IVIG), however, required a second dose due to ongoing fevers and irritability. She has had no conjunctivitis, oral ulcers, or swelling of the palms or soles and moves all her joints. Her vaccines are up to date, and there has been no recent travel or exposure to unusual animals. Her birth history is unremarkable, and she is developmentally appropriate. On examination, her weight is 10.17 kg (75th to 90th percentile), height is 77 cm (90th percentile), and head circumference is 47 cm (95th percentile). Her temperature is 98.2oF (36.8oC), heart rate is 127 beats per minute, respiratory rate is 32 breaths per minute, and blood pressure is 121/75 mm Hg, which decreases to 104/65 mm Hg when not agitated. She has hepatosplenomegaly without any evidence of lymphadenopathy. Her lungs are clear, and she has no murmur. Laboratory results reveal the following: WBC count, 28,800/μL (28.8 ×109/L), with 54% neutrophils, 12% bands, 24% lymphocytes, 7% monocytes, 1% eosinophils, and 1% basophils; hemoglobin, 5.9 …

Visual Diagnosis: 15-Year-Old Girl With Fever, Extremity Pain, and Unusual Rash

1. David Toturgul, MD* 2. Megan Yunghans, MD† 3. Jessica Kosut, MD† 1. *Atlantic Health Sports Medicine, Morristown Medical Center, Morristown, NJ. 2. †Division of Hospital Medicine, John A Burns School of Medicine, Honolulu, HI. A 15-year-old girl presents to the clinic with fever, rash, and extremity pain associated with difficulty walking. The patient had been in her usual state of health until 6 days before admission, when she developed diffuse abdominal pain, nonbilious and nonbloody emesis, and subjective fever. The patient initially had been seen in the emergency department (ED) 2 days before presentation and underwent abdominal computed tomography (CT), blood work, and urine studies. The abdominal CT revealed a normal-appearing appendix and no evidence of gastrointestinal obstruction. The blood work was notable for the following: white blood cell (WBC) count, 18,700/μL (18.7 × 109/L) with 39% band cells; hemoglobin, 15 g/dL (150 g/L); hematocrit, 43.1; platelet count, 94.0 × 103/μL (94.0 × 109/L); erythrocyte sedimentation rate, 30 mm/h; and C-reactive protein, 111 mg/L (1057 nmol/L). The urinalysis revealed 0 to 5 WBCs, 2 to 5 red blood cells, a protein level of greater than 300 mg/dL (3.0 g/L), and moderate bacteria (10-30 casts) but normal pH and negative leukocyte esterase and nitrite test results. A rapid streptococcal test result was negative. The patient was given a single dose of ceftriaxone and sent home with a prescription for a 10-day course of cephalexin for presumed urinary tract infection. The next day she followed up with her pediatrician and by that time had developed chills, extremity pain that began in her lower extremities with progression to her upper extremities, and a new rash on her palms and soles. She had not filled the cephalexin prescription and was given a new prescription for amoxicillin by her pediatrician. Later, a …

Evaluation of Leukocyte and Bacterial Interference in Point-of-Care Human Chorionic Gonadotropin Tests

We read with interest the Letter to the Editor by Jao et al. [1] which reported false positive results using the point-of-care (POC) One Step Pregnancy Test device (ACON Laboratories Inc., San Diego, CA, USA). The authors determined that false positive results occurred when the concentration of white blood cells (WBCs) in a urine specimen exceeded 0.4×109 cells/L. We recently observed several false-positive human chorionic gonadotropin (hCG) results using the POC hCG Combo Rapid Test (Cardinal Health, Waukegan, IL, USA). We observed that most of our false positive specimens were in patients with evidence of urinary tract infection (UTI) and pyuria; with this information, and in the context of the findings by Jao et al. [1] that WBCs may result in false positive hCG assays, we evaluated the effect of WBCs or bacteria in urine on the analytical performance characteristics of both devices. Two buffy coat preparations were created using pooled whole blood from 25 patients. The buffy coat preparations were analyzed using the Coulter LH 750 Hematology Analyzer (Beckman Coulter, Brea, CA, USA) to assess the purity of the preparation. WBCs were prepared on two separate occasions and the total WBC counts of the pools were 57.5×109/L and 200×109/L. These WBC preparations were then diluted into urine from a male patient at six different WBC concentrations (0.1×109, 0.4×109, 1.0×109, 5.0×109, 10.0×109, and 21.0×109/L) including and exceeding the concentration used by Jao et al. [1]. The urine was then tested on both the hCG One Step and the hCG Combo Rapid test according to the manufactures' recommendations. All specimens were negative on both devices. The explanation for the different results observed in the study by Jao et al. [1] and the current study are unclear. Jao et al. [1] do not describe the source of their WBC preparation, it is unknown if it is from one patient or multiple patients, and the WBC differential is also unknown. It is possible that differences in these parameters could explain the discrepancy. With the knowledge that most of our patients with false positive results had evidence of UTI, and knowing that Escherichia coli is the most common cause of UTI in the outpatient setting, we wondered if E. coli specifically might account for the false positive results. To test this hypothesis, we made logarithmic dilutions (107 colony forming units [CFU]/mL, 106 CFU/mL and 105 CFU/mL) of a clinical isolate of uropathogenic E. coli into sterile urine from a male patient and tested these samples on both devices; all tests yielded negative results. To account for the fact that addition of E. coli and/or WBCs to sterile urine might not accurately replicate the matrix of a clinical specimen from a patient with UTI, we then tested 10 urine specimens from unique, female patients that were culture positive for E. coli (>50,000 colonies/mL) and 5 additional urine specimens that were submitted from outpatients to the microbiology laboratory for culture for presumed UTI. All of these specimens, when tested with the hCG Combo Rapid Test, also gave negative results. A recent study by Snyder et al. [2] reported that high WBC concentrations resulted in falsely increased serum hCG concentrations using the Beckman Coulter Access Total βhCG on the UniCel DxI (Beckman Coulter, Chaska, MN, USA). According to the authors, the false positive results may be attributed to leukocyte alkaline phosphatase reacting with the conjugate that is used in those immunoassays. However, both POC devices used in this particular study use colloidal gold as the color conjugate, hence leukocyte alkaline phosphatase should not result in this specific interference. Based on the information in this study, we feel there is inadequate evidence at this time to conclude that false-positive hCG results, in either the One Step Pregnancy Test device or the hCG Combo Rapid Test, can be attributed to elevated WBC concentrations in the urine. However, we continue to see false positive results that suggest the presence of a yet unidentified interfering substance.

Visual Diagnosis: Girl With Sickle Cell Disease, Abdominal Pain, and Elevated Blood Pressure ... A Missed Opportunity

1. Elizabeth Chuang, MD, MPH* 2. Celia Ng, RN† 3. Jacqueline Ehrlich, MD, MPH† 1. *At the time this article was written, Dr Chuang was a resident at the New York City Department of Health and Mental Hygiene. She is currently with Montefiore Medical Center Palliative Care Service, Bronx, NY. 2. †New York City Department of Health and Mental Hygiene, Bureau of Environmental Disease Prevention, Lead Poisoning Prevention Program, New York, NY. A 47-month-old girl with sickle cell disease presents to the emergency department with decreased oral intake and abdominal pain for 3 days. She was diagnosed as having sickle cell disease at age 2 years and had 4 previous hospitalizations for sickle cell crisis. Current medications include oral folic acid, 5 mg/d, and penicillin weekly. Review of systems reveals a history of constipation. The patient and her family moved to the United States from Angola more than 2 years ago. She is in no distress. Her blood pressure is mildly elevated at 121/75 mm Hg, her heart rate is 99 beats per minute, her temperature is 96.8°F (36°C), and her respiratory rate is 24 breaths per minute. She has normal bowel sounds and a soft, nontender abdomen with no organomegaly. The rest of her physical examination findings are unremarkable. Laboratory testing reveals the following: hemoglobin, 8.7 g/dL (87 g/L); platelets, 186 × 103/μL (186 × 109/L); white blood cell (WBC) count, 21,000/μL (21 × 109/L), with 55% neutrophils, 24% lymphocytes, and 10% monocytes; serum aspartate aminotransferase (AST), 112 U/L (reference range, 5-40 U/L); alanine aminotransferase (ALT), 77 U/L (reference range, 7-56 U/L); and alkaline phosphatase, 159 U/L (reference range, 30-120 U/L). An abdominal radiograph is interpreted as “normal” by the emergency department (Figure 1). The urinalysis result is positive for leukoesterase with 3 to 5 red blood cells per high-power field, 30 to 50 WBCs per high-power field, some WBC casts, and large bacteria. Figure 1. Abdominal flat plate read as normal. The patient is admitted for a presumed urinary tract infection and treated with ceftriaxone …

Symptomatic Extraperitoneal Bladder Perforation Following Transurethral Bladder Surgery: Imaging with CT Urography

An 80 year-old man presented to his primary care physician with painless gross hematuria. He reported having intermittent episodes of pink urine containing small clots for about three months. He was initially treated with a single course of ciprofloxacin for presumed urinary tract infection. His symptoms did not improve with antibiotic therapy and he was then referred to our institution for a computed tomography (CT) urogram. CT urogram showed a 4 x 3.6 centimeter (cm) infiltrating solid mass along the left lateral posterior wall of the urinary bladder (Figure-1). Tumor also extended along the bladder dome. Prostate enlargement and bladder diverticula were also present. He was referred to the urology service and subsequently underwent transurethral resection of bladder tumor (TURBT) with fulguration. No intraoperative complications were noted and he returned to the recovery room in satisfactory condition on continuous bladder irrigation. Pathologic examination revealed a 5 cm transitional cell carcinoma with high grade growth pattern invading the deep muscular layer. On postoperative day one, the patient reported abdominal pain and general discomfort. Physical exam revealed a grossly distended abdomen which was tender to palpation with positive guarding and decreased bowel sounds. He Symptomatic Extraperitoneal Bladder Perforation Following Transurethral Bladder Surgery: Imaging with CT Urography _______________________________________________

Significance of First-Degree Atrioventricular Block in Acute Endocarditis—Quiz Case

A 64-YEAR-OLD MAN WITH A HISTORY OF CONgenital bicuspid aortic valve and bioprosthetic valve replacement presented with fever, chills, and dysuria. He was treated with ciprofloxacin as an outpatient for presumed urinary tract infection by his primary care physician. In the emergency center, his urinalysis result was positive. He was given intravenous ceftriaxone sodium and admitted for observation. The patient was alert and oriented to person, place, and time. He was in no acute distress. His blood pressure was 116/72 mm Hg, his heart rate was 82 beats/ min, and his axillary temperature was 39.1 C. His pupils were equal, round, and reactive, and his neck was supple without jugular venous distension. Cardiovascular examination revealed a regular rate and rhythm. A harsh grade III/VI systolic murmur, best heard in the left second intercostal space, was detected. A grade II/VI protodiastolic murmur was also noted. The point of maximal impulse was diffuse and minimally displaced toward the axilla. No rubs or gallops were noted. His lungs were clear to auscultation, and his abdomen was soft, nontender, and without hepatosplenomegaly. Cranial nerves II to XII were grossly intact. Extremities were free of any clubbing, cyanosis, or edema. Skin examination revealed no ecchymoses, purpura, or petechiae. Laboratory data revealed a leukocyte count of 7500/ L (to convert to 10 per liter, multiply by 0.001); a hemoglobin level of 12.2 g/dL (to convert to grams per liter, multiply by 10), a hematocrit level of 35.2%, and a platelet count of 105 10/ L. Findings from urinalysis were significant for 1 bacteria (negative/high-power field), 0 to 5 white blood cells (0-5 leukocytes/highpower field), and positive results for leukocyte esterase and nitrite. His troponin I level was normal ( 0.03 ng/ mL) (to convert to micrograms per liter, multiply by 1). Of 2 blood cultures obtained at 15-minute intervals, 2 were positive for gram-positive cocci in chains. Findings from 2-dimensional transthoracic echocardiography were suggestive of a possible aortic valve vegetation. The initial electrocardiogram demonstrated normal sinus rhythm with a ventricular rate of 78 beats/min, a PR interval of 194 milliseconds (ms), and a QRS duration of 168 ms, with a QTc of 526 ms. A subsequent electrocardiogram was obtained within 24 hours. Questions: What is the significant electrocardiographic change from Figure 1 to Figure 2, and how does it impact this patient’s management?

Flank Pain and Profound Anemia in an 80-Year-Old Female: Table 1

Patient: 80-year-old Caucasian female Chief Complaint: Fatigue, flank pain, and hematuria History of Present Illness: The patient was admitted to the regional hospital after transfer orders from her primary care physician (PCP) subsequent to results of a CBC and a several week history of fatigue and hematuria. The PCP gave her ciprofloxacin to treat the presumed urinary tract infection (UTI). Upon a 1-month follow-up, the patient’s symptoms had not resolved, and the PCP discontinued the ciprofloxacin and started the patient on cephalexin. The patient again presented to her PCP, prior to this admission, with flank pain, in addition to the previous symptoms. Performance of a CBC revealed a hemoglobin level of 4.6 g/dL, and the patient was subsequently transferred to the hospital for treatment of profound anemia. Past Medical and Surgical History: Hypothyroidism Family History: Multiple myeloma Social History: Tobacco use (quit 15 years ago) Physical Examination Vital Signs: Temperature: 36.2°C; pulse 82 beats per minute; respiratory rate, 20 breaths per minute; blood pressure, 133/65. Principal Laboratory Findings: Table 1 Additional Testing: Reference Lab Pre-transfusion Workup Cell Studies: Direct antiglobulin test (DAT) positive to polyspecific anti-human globulin (AHG), anti-immunoglobulin G (IgG), and anti-complement; elution studies were not performed at the time. Serum/Plasma Studies: Autoantibody Reactivity: positive Adsorption Studies: Alloadsorption performed: no alloantibodies to common antigens detected Recommendations: Group O; Rh (D) compatible; least serologically incompatible; cross-matched red cells. Consideration should be given to the use of a properly monitored blood warmer; keep all fluids warm; keep patient warm. 1. What are the patient’s most striking clinical and laboratory findings? 2. What is the differential diagnosis for a patient with these findings? 3. What is the patient’s most likely diagnosis? 4. What protocol needs to take place to differentiate among the different types of autoimmune hemolytic anemias (AIHA)? 5. What is the recommended treatment and management …