Repeat Urine Cultures Research Articles

Microbial Colonization Pattern of Indwelling Double J Stents in Children.

Indwelling double-J-stent (DJ stent) kept post-urological procedures may cause urinary tract infections (UTIs) due to polymicrobial biofilm formation and colonisation. To determine the incidence and microbiological characteristics of DJ stent related UTIs in a paediatric population. Patients under the age of 18 admitted for DJ stent removal following pediatric urological procedures were enrolled into the study. Prior to surgical removal of the DJ stent, a urine sample was collected and the stent was cystoscopically removed under anesthesia. The ends of the stent were inoculated into culture media and incubated up to 48 hours. When growth was observed, an antibiogram was obtained using a panel of anti-microbial agents. The study group consisted of 27 patients (M: F = 23:4) with a mean age of 4.3 years (1 month - 13 years). The commonest indication for stent placement was Pyeloplasty, 19 (70%). Stent colonisation was found in 8 out of 27 patients (29.6%; CI 12-51%) and E.Coli (33%) was the commonest organism. Polymicrobial growth was noted in 4 patients. Organisms were sensitive to Cephaerazone/ Sulbactam and Amikacin, and resistant to other Cephalosporins. All 8 culture positive patients were asymptomatic and a repeat urine culture revealed no growth. Colonisation did not lead to active UTI and post stent removal the urine became sterile. Microbial colonisation was noted in 30% of patients with indwelling DJ stents. Prior knowledge of culture & sensitivity pattern helps to cover the patients with appropriate antibiotic on the day of stent removal.

Brucella Prostatitis: A Rare Manifestation of Fever of Unknown Origin, Detected by FDG PET/CT.

FDG PET/CT is a well-documented imaging investigation to evaluate fever of unknown origin (FUO). Brucellosis is one of the causes of FUO, which can be missed as it requires a longer incubation period for growth on culture media. Rarely, it can involve the prostate. Here, we present a case of FUO with initial negative blood and urine cultures and no localizing signs or symptoms. 18F-FDG PET/CT revealed hypermetabolism in the prostate and seminal vesicles. A repeat blood and urine culture showed the growth of Brucella species after 5 days of incubation, and the patient responded to Brucella-directed antibiotic therapy.

Bacteriology and clinical outcomes of urine mixed bacterial growth in pregnancy.

The objective was to analyse the risk of significant bacteriuria in repeat urine cultures from pregnant women, following initial mixed bacterial results. This retrospective study examined maternal characteristics and clinical features of women who repeated urine cultures due to previous mixed cultures results. Of 262 women included, 80 (30.5%) had negative cultures and 125 (47.7%) had mixed bacterial growth in their repeat cultures. Positive results (≥104 CFU/ml of a urinary pathogen) were obtained for 57 women (21.8% [95% CI 17.1-27.0]). For 37 (14.1%), the repeat specimen grew 104-105 CFU/ml of microorganisms; whereas for 20 women (7.6% [95% CI 4.9-11.3]), it grew ≥105 CFU/ml. Among women with positive (>104 CFU/ml) compared with those with negative or mixed growth, rates of urinary symptoms were higher (38.6% vs 23.4%, p=0.028), abnormal dipstick results (49.1% vs 21.0%, p<0.001) and hydronephrosis, as demonstrated by renal ultrasound (12.3% vs 2.0, p=0.003). In a multivariate logistic regression analysis, hydronephrosis was associated with the occurrence of a positive repeat culture (aOR = 10.65, 95% CI 2.07-54.90). The sensitivity and specificity for predicting a repeat urine culture with ≥105 CFU/ml were 12.9% and 94.3% respectively, for urinary symptoms; and 19.7% and 97.4% respectively, for abnormal dipstick results. Mixed bacterial growth might represent a true urinary tract infection in a considerable proportion of women who are symptomatic and have an abnormal dipstick urinalysis.

Reduction of Patient Harm Through Decreasing Urine Culture Contamination in an Emergency Department Using Multiple Process Improvement Interventions

BACKGROUND: From August 2018 to January 2019, the baseline urine sample contamination rate at an acute care hospital emergency department (ED) was 51%. Urine culture contamination is associated with unnecessary antibiotic use, repeat culture costs, and unnecessary inpatient admissions. These outcomes can lead to additional cost to the patient and healthcare system while leading to additional poor outcomes. METHODS: Culture results were reviewed and the project definition of contamination was applied. Contaminated cultures were reviewed further via manual electronic health record review of ED notes to determine documentation of collection source, education prior to clean catch collection, the cognitive and physical documented descriptions of the patient, and the name of the staff member who collected the sample. INTERVENTION: Staff were educated on appropriate midstream and straight catheter collection techniques, verbal along with picture education for patients, and appropriate identification of patients who may benefit from straight catheterization instead of clean catch. RESULTS: The combined interventions resulted in a six-month decrease of contaminated urine samples from the initial 51% to &lt;10%, resulting in an 80% decrease. CONCLUSION: Urine culture contamination in an acute care ED was sustainably decreased through multiple process improvement interventions. Secondary outcomes included reduction in unnecessary antibiotic use, repeat urine cultures, and unnecessary admissions.

Impact of electronic alerts on repeat urine culture testing: Analysis from a large academic medical center.

Impact of electronic alerts on repeat urine culture testing: Analysis from a large academic medical center.

ALCALIGENES FAECALIS, AN UNEXPECTED AGENT OF URINARY TRACT INFECTION IN A 14-YEARS-OLD BOY

Introduction: Alcaligenes faecalis is a rare cause of urinary tract infection (UTI) in humans, especially in pediatrics. It is a potentially emerging pathogen, usually opportunistic, and it is often difficult to treat due to its increased resistance to several antibiotics. Urinary tract infection due to Alcaligenes faecalis in pediatrics it is not yet describe in literature. Case report: We report the occurrence of Alcaligenes faecalis (spp faecalis) Urinary Tract Infection (UTI), presenting as acute cystitis, in a 14-years-old boy with previous history of non-obstructive bilateral renal lithiasis due to hyperuricosuria, pyelocaliceal duplicity in the right kidney and recurrent UTI. He was treated with empirical antibiotic with amoxicillin/clavulanate, with clinical improvement. A repeated urine culture was sterile after treatment. Discussion: We review literature in pediatrics, and we found out that this agent is a very uncommon organism of infection and difficult to treat due to its increased resistance to several antibiotics such as penicillin, cephalosporins, carbapenems, aminoglycosides, and quinolones. In pediatric literature, there is still few cases of infection described, due to Alcaligenes faecalis. Conclusions: Clinicians should continue to direct initial empiric antimicrobial therapy toward the more commonly encountered bacteria. If Alcaligenes faecalis is identified in culture, it can represent a true pathogen, and not merely a contaminant. Alcaligenes faecalis is an unexpected agent of UTI that clinicians should keep in mind.

Staphylococcus aureus bacteriuria: implications and management.

Staphylococcus aureus is isolated in around 0.2%-4% of positive urinary cultures, more commonly in the contexts of long-term care, urological abnormalities and procedures, male sex, older age and comorbidities. Isolation may represent contamination, colonization, urinary tract infection or bacteraemic seeding from another site, and may be linked to S. aureus bacteraemia. However, there is little guidance on investigation and management of S. aureus bacteriuria. We performed a retrospective analysis of cases in our service, including clinical characteristics, investigations and treatment. Data were collected on all urine samples taken from adult patients over a 5-year period from which S. aureus was isolated. Detailed analysis including investigations and management was conducted in those collected over a 1-year period. From 511 patients, 668 urine cultures positive for S. aureus were identified; 6.5% of cases were positive for MRSA. Of 93 patients who had blood cultures taken, there were 6 cases of S. aureus bacteraemia, 4 of which were associated with urological instrumentation. Of 94 cases analysed in detail, 57% were treated with antibiotics, and 49% had repeat urine cultures. Factors associated with recurrence were urinary catheterization, urological abnormality, diabetes and inpatient status. Our experience does not support the routine taking of blood cultures or treatment of asymptomatic bacteriuria in well patients with S. aureus bacteriuria in this setting. However, repeat urine culture, and investigation and treatment of higher risk patients, for example, prior to bladder instrumentation, may be warranted. We propose a simple algorithm to guide clinicians.

680. Utility of Cefoxitin for the Treatment of ESBL-producing E. coli Urinary Tract Infections

Abstract Background Carbapenems are regarded as first-line agents for the treatment of ESBL-producing bacterial infections, even when in vitro activity to other beta lactams is demonstrated. However, overuse is associated with the selection of beta-lactamases that can hydrolyze carbapenems. Patients with isolated urinary tract infections due to ESBL–producing E. coli potentially have a lower burden of infection ("low inoculum"). These patients are frequently less ill and may benefit from non-carbapenem therapy. Cephamycins have in vitro activity against ESBL–producing Enterobacterales, and may be useful in the treatment of ESBL E. coli urinary tract infections as a carbapenem sparing agent. Methods Patients 18 years of age and older, hemodynamically stable with negative blood cultures and who demonstrated signs and symptoms of a urinary tract infection with a urine culture showing ESBL E. coli, were eligible to participate. Patients were started on initial antimicrobial therapy at the discretion of the admitting physician, and if the urine culture showed ESBL E. coli with an MIC of less than 8, the antimicrobial stewardship team requested to switch the patient to Cefoxitin 2 g intravenously every 6 hours, via extended infusion. The dose was renally adjusted as appropriate, and patients with beta-lactam allergies were excluded. Results 46 patients were evaluated between May 2017-April 2022. Patients received antibiotics for 2.6+1 day before the switch to Cefoxitin. The mean duration of therapy with Cefoxitin was 4.5+2.2 days. All 46 patients had resolution of fever and dysuria. Six patients were readmitted within 30 days, but none were due to a urinary tract infection. 30 patients had a repeat urinalysis at 48 hours, and all demonstrated reduction in pyuria. 39 patients had a repeat urine culture following completion of therapy, and 36 had converted to culture-negative status. Conclusion Cefoxitin is a useful agent for the treatment of ESBL E. coli urinary tract infections. The optimal dose appears to be 2 g intravenously every 6 hours, via extended infusion, in patients with normal creatinine clearance. Further larger studies, involving patients with pyelonephritis, are needed to validate these findings. Disclosures Ramesh V. Nathan, MD, Eli Lilly: Grant/Research Support|PPD: Grant/Research Support.

Hidden in plain sight: urinary Cryptococcus neoformans missed by routine diagnostics in a patient with acute leukemia

Cryptococcuria is a rare manifestation of localized cryptococcal disease. We present a case of Cryptococcus neoformans urinary tract infection in an immunocompromised host missed by routine laboratory workup. The patient had negative blood cultures, a negative serum cryptococcal antigen (CrAg), and “non-Candida yeast” growing in urine culture that was initially dismissed as non-pathogenic. The diagnosis was ultimately made by matrix-assisted laser desorption/ionization time-of-flight mass spectrometry (MALDI-TOF MS) from a repeat urine culture after transfer to a tertiary care center. Cryptococcus should be considered in the differential of refractory urinary tract infections growing non-Candida yeast.

Prevalence and antimicrobial sensitivity of asymptomatic bacteriuria among sickle cell anaemia patients in Aminu Kano Teaching Hospital, Nigeria

Introduction: Urinary tract infection (UTI) is a common cause of morbidity in children with sickle cell anaemia (SCA) and may present as asymptomatic bacteriuria. Asymptomatic bacteriuria is often under-diagnosed and may lead to long term renal complications.&#x0D; Aim: This study compared the prevalence of asymptomatic bacteriuria, bacterial isolates and their antimicrobial sensitivity in children with and without SCA seen at Aminu Kano Teaching Hospital.&#x0D; Subjects and Methods: This cross-sectional study recruited 139 children with SCA in stable state and 139 children without SCA aged 1- 15 years. All children were tested for asymptomatic bacteriuria using clean catch or mid-stream urine samples. Children whose samples yielded significant bacteriuria (≥105cfu/ml) had a repeat urine culture within a week to confirm asymptomatic bacteriuria.&#x0D; Results: Both study groups had a mean age of 4.25 years ± 3.04, and a male: female ratio of 1.4:1. The prevalence of asymptomatic bacteriuria was higher in children with SCA(5.8%) compared to children without SCA (1.4%). Asymptomatic bacteriuria was more common among females in both study groups. The most common isolate in both groups was E. coli. Majority of the isolates were sensitive to quinolones, gentamycin and nitrofurantoin but resistant to commonly used antibiotics like amoxicillin and cotrimoxazole.&#x0D; Conclusion: Asymptomatic bacteriuria is more common in children with SCA than those without SCA. Majority of isolated pathogens showed low susceptibility to ampicillin, amoxicillin, cotrimoxazole and nalidixic acid, this implies that the use of these drugs for empirical or first line treatment for UTI in children with SCA should be avoided.

Emergence of Extended-Spectrum β-Lactamase-Producing Pathogens in Community-Acquired Urinary Tract Infections Among Infants at a Pediatric Emergency Department.

Extended-spectrum β-lactamase (ESBL)-producing pathogens are common among adults and are associated with extended and multiple hospitalizations. They cause urinary tract infections (UTIs) among children with known risk factors such as urinary tract abnormalities and antimicrobial prophylaxis. The emergence of UTIs caused by ESBL-producing organisms among infants has not been well characterized. We sought to describe the incidence and current clinical management of infants who were diagnosed with UTIs caused by ESBL-producing organisms at a pediatric emergency department (ED). In addition, we sought to describe risk factors associated with inpatient hospitalization for UTIs caused by ESBL-producing organisms. We retrospectively identified infants who were treated in the ED from 2013 to 2017 and who had positive urinalyses and urine cultures positive for greater than 50,000 colony-forming unit per milliliter of a single ESBL-producing urinary pathogen. We abstracted details of clinical management and known previous risk factors, including prior neonatal intensive care unit hospitalization stay, prior UTI caused by an ESBL-producing organism, and known urologic abnormalities. Forty-five UTIs caused by ESBL-producing organisms occurred in 43 patients (mean age of 5.9 months and 59% female)-ESBL Escherichia coli represented the majority (42/45). The incidence of UTIs caused by ESBL-producing organisms ranged from 0.9% to 4.5% during the 5-year study period. The 13 patients (26%) admitted from the ED were significantly younger than discharged patients (1.9 vs 6.7 months, P = 0.016) and more likely to have had prior neonatal intensive care unit hospitalizations (50% vs 15.6%, P = 0.0456). Of the 33 visits (77%) resulting in initial outpatient management, 5 were followed by readmission for parenteral antibiotic treatment. Of those who were readmitted, 40% (n = 2) were afebrile at the time of admission. The remainder (28/33) completed outpatient oral antibiotic courses guided by susceptibilities. Two patients (4%) had negative repeat urine cultures despite in vitro resistance to initial antibiotic coverage. Extended spectrum β-lactamase-producing organisms are an increasing cause of UTIs in infants presenting at a pediatric ED, and outpatient management may be reasonable for infants older than 2 months.

Urinary tract infection in children with Nephrotic syndrome: One of the hurdles for primary care physician and pediatrician towards timely diagnosis and optimum management of the disease.

Urinary tract infection (UTI) is a common infection in children with nephrotic syndrome (NS). Clinical experience suggests that childhood nephrotic syndrome is frequently diagnosed incorrectly and managed inadequately on the top of this existing UTI in the episode becomes an additive obstacle for the primary care physicians or pediatricians towards optimum management, leading to poor outcome. So, we have conducted this clinico- microbiological study of UTI in NS in children to provide the exact picture of UTI with NS so that the primary care providers can be helped in having high index of suspicion of this infection and knowing prevalent organisms and their antimicrobial sensitivity pattern. The aim of the study was to study clinical features and identify the responsible organisms with its drug sensitivity pattern with response to treatment in various types and stages of NS with UTI in children. This cross-sectional hospital based study was conducted on 50 children of 2-18 years of age with NS attending nephrology clinic or admitted to the Paediatric ward of AIIMS, Rishikesh. Demographic, clinical, and microbiological data were recorded and details were entered in a predesigned proforma sheet. Out of 50 cases, 8 (16%) had a positive urine culture. Six (75%) out of them had first episode and two (25%) were frequent relapsers of NS. Fever, decreased urine output, and generalized edema were the presenting features. The most common bacteria responsible for UTI was Pseudomonas aeruginosa (in around 25% isolates). Escherichia coli and Citrobacter koseri were the most resistant organisms. Patients were treated with antibiotics according to sensitivity pattern which resulted in resolution of symptoms and repeat urine culture became sterile subsequently. About one-sixth of children with Nephrotic Syndrome had UTI. UTI should be ruled out in every case of NS in active phase to prevent long-term morbidity and mortality.

Urine Trouble: Reducing Midstream Clean Catch Urine Contamination Among Children 3-17 Years Old.

Children, caregivers, and clinicians often prefer midstream clean catch technique to urethral catheterization for obtaining urine cultures. However, contamination is common, potentially resulting in unnecessary medical intervention and cost. With this resident-led initiative, we aimed to reduce pediatric midstream clean catch urine culture contamination over 6 months. A bundled intervention was implemented in the emergency department, inpatient units, and outpatient clinics at our institution. Baseline contamination rates were collected April 2016 to September 2017; the intervention was introduced October 2017 to March 2018 and evaluated April 2018 to September 2018. Sustainability was measured October 2018 to September 2020. Balancing measures included rates of repeat urine cultures, positive cultures, and contaminated cultures by urethral catheterization. Rates of midstream clean catch urine culture contamination were 45.3% preintervention and 30.9% postintervention, a 14.7% (95% confidence interval: 8.0% to 21.5%) absolute decrease. Before and after intervention, girls and patients 16 to 17 years old had the highest rates of midstream clean catch contamination. Six months postintervention, the rate of repeat urine culture decreased from 4.9% to 0.9% with no change in positive culture results or contaminated cultures by urethral catheterization. Over the subsequent 2 years, the impact of the intervention decreased (rate of contamination over 30 months postintervention: 38.4%, a 7.3% [95% confidence interval: 2.9% to 11.6%] absolute decrease; rate of repeat urine culture: 3.2%). An intervention to improve midstream clean catch urine culture collection was associated with a clinically meaningful decrease in contamination. Impact of the resident-led intervention decreased over time.

Serratia Fonticola microbe presented as a community-acquired urinary tract infection (UTI): a case report

Background: The case we are presenting is about one of the rare pathogens, Serratia Fonticola (SF) that may cause urinary tract infection. &#x0D; Case Presentation: A 58 years-old female presented with dysuria, suprapubic pain, frequency of micturition, and change in urine color. The patient was afebrile on physical examination; however, the urine culture was positive to SF as the sole isolate. The patient received levofloxacin tables (750 mg) once a day for 5 days along with supportive instructions to improve hygiene. On follow-up, she was free of symptoms and the repeated urine culture was negative.&#x0D; Conclusion: This case can be considered globally the third that diagnosed in the urine culture of the asymptomatic patient.&#x0D; &#x0D; References&#x0D; &#x0D; Geerlings SE. Clinical presentations and epidemiology of urinary tract infections. Microbiol. Spectr. 4, 2016. https://doi.org/10.1128/9781555817404.ch2&#x0D; Flores-Mireles AL, Walker JN, Caparon M, Hultgren SJ. Urinary tract infections: epidemiology, mechanisms of infection and treatment options. Nat Rev Microbiol. 2015 May;13(5):269-84. https://doi.org/10.1038/nrmicro3432&#x0D; Gavini F, Ferragut C, Izard D, Trinel PA, Leclerc H, Lefebvre B, Mossel DA. Serratia fonticola, a new species from water. International Journal of Systematic and Evolutionary Microbiology. 1979;29(2):92-101. https://doi.org/10.1099/00207713-29-2-92&#x0D; Aljorayid A, Viau R, Castellino L, Jump RL. Serratia fonticola, pathogen or bystander? A case series and review of the literature. IDCases. 2016 May 24; 5:6-8. https://doi.org/10.1016/j.idcr.2016.05.003&#x0D; Müller HE. Isolation of Serratia fonticola from birds. Zentralblatt Bakteriol Mikrobiol Und Hyg - Abt 1 Orig A 1986; 261:212–8. https://doi.org/10.1016/s0176-6724(86)80038-4&#x0D; Garcia ME, Lanzarot P, Costas E, Lopez Rodas V, Marín M, Blanco JL. Isolation of Serratia fonticola from skin lesions in a Nile Crocodile (Crocodylus niloticus) with an associated septicaemia. Vet J. 2008 May;176(2):254-6. https://doi.org/10.1016/j.tvjl.2007.02.025.&#x0D; Bollet C, Gainnier M, Sainty JM, Orhesser P, De Micco P. Serratia Fonticola isolated from a leg abscess. J Clin Microbiol 1991; 29:834–5. https://doi.org/10.1128/JCM.29.4.834-835.1991&#x0D; Farmer JJ 3rd, Davis BR, Hickman-Brenner FW, McWhorter A, Huntley-Carter GP, Asbury MA, Riddle C, Wathen-Grady HG, Elias C, Fanning GR, et al. Biochemical identification of new species and biogroups of Enterobacteriaceae isolated from clinical specimens. J Clin Microbiol. 1985 Jan;21(1):46-76. https://doi.org/10.1128/JCM.21.1.46-76.1985&#x0D; Stock I, Burak S, Sherwood KJ, Gruger T, Wiedemann B. Natural antimicrobial susceptibilities of strains of 'unusual' Serratia species: S. ficaria, S. fonticola, S. odorifera, S. plymuthica and S. rubidaea. J Antimicrob Chemother. 2003;51(4):865-85. https://doi.org/10.1093/jac/dkg156.&#x0D; Gorret J, Chevalier J, Gaschet A, Fraisse B, Violas P, Chapuis M, Anne JG. Childhood delayed septic arthritis of the knee caused by Serratia fonticola. Knee 2009; 16 (6):512–4. https://doi.org/10.1016/j.knee.2009.02.008&#x0D; Hai PD, Hoa LTV, Tot NH, Phuong LL, Quang VV, Thuyet BT, Son PN. First report of biliary tract infection caused by multidrug-resistant Serratia fonticola. New Microbes New Infect. 2020; 36:100692. https://doi.org/10.1016/j.nmni.2020.100692&#x0D; &#x0D; Conclusion: This case can be considered globally the third that diagnosed in the urine culture of the asymptomatic patient.

Urinary Tract Infections Caused by Community-Acquired Extended-Spectrum β-Lactamase-Producing Enterobacteriaceae in a Level III Hospital - A Retrospective Study

The emergence of β-lactamases producing bacteria is a problem worldwide, with increasing importance in communityacquired infections, especially in urinary tract infections. Data regarding the use of non-carbapenem antimicrobials in these infections are scarce. The aim of this study was to analyse the treatment and outcome of urinary tract infections caused by community-acquired β-lactamase-producing bacteria in children. Retrospective study performed in a level III paediatric hospital, between June 2007 and December 2017. All children with β-lactamase-producing Enterobacteriaceae identified in aseptically collected urine culture were included. A total of 175 urinary infections caused by β-lactamases producing bacteria were diagnosed, 34 (19%) were community-acquired: 25 Escherichia coli (74%), 4 Klebsiella pneumoniae (12%), 4 Proteus mirabilis (12%) and 1 Proteus vulgaris (3%). In 30 (88%) cases, it was the first urinary infection. After identification of the microorganism and antimicrobial susceptibility, 33 (97%) children were re-evaluated and 24 (71%) had a repeat urine culture, which was positive in three (13%). In six (18%) cases, antibiotic treatment was modified. Four (12%) children had another UTI in the following month. In 30 (88%) children, imaging was carried out, with no nephrourological malformations detected. In the last decade, about 20% of urinary infections caused by β-lactamase-producing Enterobacteriaceae were community-acquired with a relatively stable number of cases over the years. No nephro-urological malformations were identified in these children. Although the number of cases is small, the clinical and microbiological outcomes showed that most were successfully treated with non-carbapenem antibiotics, with low recurrence of new episodes of urinary tract infections.

Care Right Where You Are: Treating in Place to Avoid an Emergency Department Visit or Hospitalization

Care Right Where You Are: Treating in Place to Avoid an Emergency Department Visit or Hospitalization

SUN-332 POST TRANSPLANT GRAFT ABSCESS IN HEPATITIS-B POSITIVE RECIPIENT

Graft-site candidiasis is a rare manifestation of invasive fungal infections, with a risk of 1.3% in kidney transplants. The incidence of graft-site candidiasis is 0.1% in renal transplant recipients. Preservation of the renal graft is rarely possible when candidiasis is accompanied by vascular complications. A 24 year old male, with end-stage renal disease due to right solitary kidney with grade-3 vesicoureteric reflux, underwent left live-related donor kidney transplant with 2/6 HLA mismatch. He tested positive for Hepatitis B surface antigen, prior to continuation of maintenance hemodialysis at our center, and underwent hemodialysis for 1 year prior to transplant, hemodialysis access being left IJV cuffed hemodialysis catheter. The donor being his mother, was 45 years old, without any comorbidities. The recipient underwent right laparoscopic nephroureterectomy, on the same day, prior to transplantation. The patient received induction with Inj Grafalon, (an anti-human T-lymphocyte immunoglobulin from rabbits), intraoperatively, followed by triple-drug therapy with Tacrolimus, Prednisone, and Mycophenolate sodium. Urinary catheter, abdominal drain, left IJV cuffed hemodialysis catheter were removed prior to discharge. on day 9 he was discharged with DJ stent insitu and a baseline creatinine of 1.6 mg/dL. 19 days post transplant, he presented with facial puffiness, 4-6 loose stools, vomiting, 9 kg weight gain, oliguria and azotemia. There was no history of fever, vomiting, dysuria, bleeding manifestation, abdominal pain. He was hemodynamically stable with a hemoglobin of 7.4g%, TLC 5200/µL, Platelet 95000/ µL, serum urea and creatinine of 156 mg/dL, 6.6 mg/dL respectively. His spot UPCR was 8.3 and urine had 3+ proteinuria, 80 – 90 RBC / hpf, 15 – 20 Pus cells / hpf. His abdominal sonography was suggestive of pyelonephritis of the transplanted kidney & graft vessel doppler was normal. Urine culture was suggestive of Klebsiella pneumoniae and was treated as per antibiotic sensitivity. Due to persistent anuria, and a rising trend of serum creatinine with severe metabolic acidosis and refractory hyperkalemia, he underwent hemodialysis, via left femoral uncuffed hemodialysis catheter. DJ stent was removed. Repeat urine and blood cultures showed no growth. Stool culture also showed no growth. Repeat abdominal ultrasonography & CT-KUB were suggestive of pyonephrosis of transplanted kidney. He underwent right IJV cuffed hemodialysis catheter insertion and was put on thrice weekly maintenance hemodialysis. Post-transplant day-70, he underwent graft nephrectomy. Histopathology of multiple sections of the graft showed focal areas of abscess with non-septate fungal hyphae, numerous foreign body and langhan’s giant cells mixed with lymphohistiocytic inflammatory cells with epitheloid cells. There was evidence of tubulitis, glomerulonephritis with vessels showing hyaline arteriolar sclerosis with areas of infarcts. Sections from the ureter showed inflammatory cell infiltration of transitional epithelium and the walls showed candida, conclusive with Pyelonephritis due to candidiasis (Banff category 6). Diagnosis of fungal infection in transplant recipients can be perplex due to vague patient symptoms and lack of specificity of blood test or radiologic findings. The paucity of data regarding their management poses a challenge to transplant physicians.

Incidence and Diagnostic Yield of Repeat Urine Culture in Hospitalized Patients: an Opportunity for Diagnostic Stewardship.

There is limited knowledge on the incidence, diagnostic yield, and cost associated with inappropriate repeat urine cultures. The factors that affect repeat urine culturing practices are not well understood. We conducted a retrospective study of adult inpatients who had ≥1 urine culture performed during their hospitalization between January 2015 and February 2018. We analyzed the proportion of inappropriate repeat urine cultures performed <48 h after the index culture. We defined an inappropriate repeat urine culture to be a repeat urine culture performed following a negative index culture or a repeat urine specimen obtained from the same urinary catheter. Overall, 28,141 urine cultures were performed on 21,306 patients. There were 2,060 (7.3%) urine cultures repeated in <48 h. Of these, 1,120 (54.4%) urine cultures were inappropriate. Predictors for inappropriate repeat urine cultures included collection of the initial urine sample for culture in the emergency department (adjusted odds ratio [aOR], 5.65; 95% confidence interval [CI], 4.70 to 6.78), male gender (aOR, 1.61; 95% CI, 1.42 to 1.84), congestive heart failure (aOR, 1.20; 95% CI, 1.03 to 1.38), and a longer hospital stay (aOR, 1.01 per day; 95% CI, 1.00 to 1.01). A patient with an index urine culture obtained from an indwelling catheter (aOR, 0.65; 95% CI, 0.53 to 0.80) was less likely to have an inappropriate repeat culture. Among 1,120 negative index urine cultures, only 4.7% of repeat cultures were positive for bacteriuria. The estimated laboratory charges for inappropriate repeat urine cultures were $16,800 over the study period. Among inpatients, over half of all urine cultures repeated in <48 h were inappropriate. This offers an opportunity for diagnostic stewardship and optimization of antimicrobial use.

A single intravesical instillation of Lactobacillus rhamnosus GG is safe in children and adults with neuropathic bladder: A phase Ia clinical trial

Context/objective: Manipulation of the microbiome is an emerging approach to promote health. We conducted a Phase Ia safety study of a single bladder instillation of probiotics in asymptomatic patients with neuropathic bladder to determine the tolerability and safety of a single Lactobacillus instillation. Design: Phase Ia safety study. Setting: Outpatient rehabilitation clinic at a rehabilitation hospital (adults) and urology clinic at a free-standing children’s hospital (children). Participants: Ten patients with neuropathic bladder were included: five children with spina bifida and five adults with spinal cord injury. Interventions: A single Lactobacillus rhamnosus GG (Culturelle, 20 billion live organisms) instillation. Outcome measures: After the instillation, participants self-monitored symptoms using the Urinary Symptoms Questionnaire for People with Neuropathic Bladder using Intermittent Catheterization daily for one week. Repeat urinalysis, urine culture, and 16S bacterial rRNA-based microbiome analyses were performed 7–10 days after instillation. Results: Probiotic instillation was well-tolerated. One child had upper respiratory tract symptoms during the trial, and two had transient cloudy urine. No adults reported any symptoms following instillation. Lactobacillus did not grow on culture post-instillation. There were differences in beta diversity of the urine microbiome in children vs. adults with neuropathic bladder (P < 0.0156). Lactobacillus was present in the pre-instillation urinary microbiomes all of the adults and 4 out of 5 of the pediatric subjects, and identified in 4 out of 5 of both the adult and pediatric subjects’ post-instillation urinary microbiomes. Conclusion: Intravesical instillation of Culturelle probiotic may be safe and well-tolerated in patients with neuropathic bladder.

Inflammatory pseudotumor of urinary bladder: A masquerader of bladder malignancy

Inflammatory pseudotumor of urinary bladder is a rare benign disease of unknown etiology, characterized by nonneoplastic proliferation of fibroblastic spindle cells, in a background of myxoid and granulation tissue. We report a case of an inflammatory pseudotumor of urinary bladder and discuss the important differentials. A 47-year-old woman presented with longstanding frequency and urgency of micturition. Ultrasound pelvis, color Doppler, computed tomography, and magnetic resonance imaging were performed. Focal bladder wall thickening at the dome was observed. In addition, there was a heterogeneous solid cystic intramural lesion within this bladder wall thickening showing peripheral rim enhancement with nonenhancing central component. Repeated urine cultures were sterile and urine cytology was found to be negative for malignancy. Finally, histopathology and immunohistochemistry confirmed this lesion to be inflammatory pseudotumor.