Severe Urinary Tract Infection Research Articles

A Management of Ureteral Obstruction After Lichtenstein Tension-Free Hernia Repair in a Kidney Transplant Recipient: A Case Report

The number of renal transplants has been increasing in recent years. Recent literature data show that abdominal operations performed on patients who undergo renal transplant have higher morbidity and mortality. A 49-year-old man who had received a renal transplant from a living donor 19 years ago underwent Lichtenstein tension-free hernia repair. Anuria was observed after the operation. Renal ultrasound demonstrated massive hydronephrosis and an elevated serum creatinine level (4.6 mg/dL). It was thought that the ureter may have been obstructed because of the operation, and, with the patient under local anesthesia, all sutures and polypropylene mesh were removed. Urine output was still not present, so a percutaneous nephrostomy catheter was inserted to normalize renal function. The patient underwent reoperation under general anesthesia 45 hours after the first operation. It was observed that the ureter was ligated during high ligation. The ureter was released, and no additional intervention was performed. The patient was discharged 6 days later with a return to basal creatinine level and a percutaneous nephrostomy catheter. The patient was hospitalized twice for severe urinary tract infection and urosepsis within 3 months and received appropriate treatment. The patient has had an uneventful postoperative course for 18 months. Inguinal hernia repair is seen as a safe surgical procedure, but the risk of emerging urological complications is higher in patients with renal transplant. Imaging before surgery to identify the anatomy of the kidney and ureter may be useful. Delicate dissection of the extraperitoneal area during the operation will reduce surgical complications.

Safety and Efficacy of Rituximab in Children with Steroid-Dependent or Resistant Nephrotic Syndrome

Backgroundand Aim:Rituximab is a novel therapy that can help patients with steroid-dependent or resistant nephrotic syndrome.The aim of this study was to evaluate the efficacy of rituximab in children with corticosteroid-dependent and resistant nephrotic syndrome and to determine the factors associated with its efficacy. Methods:In this study, 40 children with corticosteroid-dependent or resistant nephrotic syndrome who were treated with rituximab in Dr. Sheikh Hospital,Mashhad,between 2014 and 2018 were enrolled. Patients with a history of hematuria, severe urinary tract infection, or secondary nephrotic syndrome were excluded. Results:The mean age of patients was 11.9 ± 5.04 years, and 55% were female. The most common underlying pathology of nephrotic syndrome was focal segmental glomerulonephritis (FSGS) (42.5%) followed by membranoproliferative glomerulonephritis (MPGN) and minimal change disease (MCD). Most of the participants (62.5%) were steroid-dependent and the rest (27.5%) were steroid resistant. Only 10% of the patients showed complications following rituximab administration and 57.5% went into complete remission. A negative family history and steroid-dependent nephrotic syndrome were significantly associated with a better treatment response. Moreover, patients with steroid-resistant nephrotic syndrome were more likely to have a positive family history, while factors associated with steroid response included underlying pathology, gender, and family history. Conclusion: Rituximab can cause remission in more than half of the patients with steroid-resistant or dependent nephrotic syndrome. Moreover, the only factors that reduce response to rituximab are a history of corticosteroid resistance and a positive family history of nephrotic syndrome.

Risk factors of multidrug-resistant bacteria in community-acquired urinary tract infections.

Urinary tract infections (UTIs) are one of the most seen infection among community. In this cross-sectional study we aimed to investigate the risk factors of multidrug-resistant (MDR) bacteria that caused community-acquired UTI (CA-UTI). Consecutive patients admitted to the Urology and Infectious Diseases policlinics with the diagnosis of CA-UTI were included in the study. A standard form including possible predisposing factors for MDR bacteria was applied. In total, 240 patients (51.3% females) were enrolled in the study. The mean age of participants were 59.8 ± 18.3 years old. Escherichia coli (n =166; 69.2%)was the most frequently isolated bacteria and its incidence was higher in females than in males (p=0.01). In total, 129 (53.8%) of the identified pathogens were MDR bacteria. According to multivariate analysis, the use of antibiotics three or more times increased the risk of infection with MDR bacteria by 4.6 times, the history of urinary tract infection in the last 6 months by 2 times, being male and over 65 years old by 3 times. Doctors should consider prescribing broad-spectrum antibiotics in patients with severe UTIs with a history of UTI, advanced age, male gender, and multiple antibiotic usage, even if they have a CA-UTI.

Comparative Effectiveness and Safety of Sodium-Glucose Cotransporter 2 Inhibitors Versus Glucagon-Like Peptide 1 Receptor Agonists in Older Adults.

Both sodium-glucose cotransporter 2 inhibitors (SGLT2i) and glucagon-like peptide 1 receptor agonists (GLP-1RA) demonstrated cardiovascular benefits in randomized controlled trials of patients with type 2 diabetes (T2D) generally <65 years old and mostly with cardiovascular disease. We aimed to evaluate the comparative effectiveness and safety of SGLT2i and GLP-1RA among real-world older adults. Using Medicare data (April 2013-December 2016), we identified 90,094 propensity score-matched (1:1) T2D patients ≥66 years old initiating SGLT2i or GLP-1RA. Primary outcomes were major adverse cardiovascular events (MACE) (i.e., myocardial infarction, stroke, or cardiovascular death) and hospitalization for heart failure (HHF). Other outcomes included diabetic ketoacidosis (DKA), genital infections, fractures, lower-limb amputations (LLA), acute kidney injury (AKI), severe urinary tract infections, and overall mortality. We estimated hazard ratios (HRs) and rate differences (RDs) per 1,000 person-years, controlling for 140 baseline covariates. Compared with GLP-1RA, SGLT2i initiators had similar MACE risk (HR 0.98 [95% CI 0.87, 1.10]; RD -0.38 [95% CI -2.48, 1.72]) and reduced HHF risk (HR 0.68 [95% CI 0.57, 0.80]; RD -3.23 [95% CI -4.68, -1.77]), over a median follow-up of ∼6 months. They also had 0.7 more DKA events (RD 0.72 [95% CI 0.02, 1.41]), 0.9 more LLA (RD 0.90 [95% CI 0.10, 1.70]), 57.1 more genital infections (RD 57.08 [95% CI 53.45, 60.70]), and 7.1 fewer AKI events (RD -7.05 [95% CI -10.27, -3.83]) per 1,000 person-years. Among older adults, those taking SGLT2i had similar MACE risk, decreased HHF risk, and increased risk of DKA, LLA, and genital infections versus those taking GLP-1RA.

The incidence of severe urinary tract infection increases after hip fracture in the elderly: a nationwide cohort study

Although urinary tract infection (UTI) is a common perioperative complication among elderly patients with hip fracture, its incidence and effects are often underestimated. This study investigated the effects of severe UTI (S-UTI) on elderly patients with hip fracture and the risk factors for this condition. In this retrospective nationwide cohort study, we searched Taiwan’s National Health Insurance Research Database from 2000 to 2012 for data on patients aged ≥ 50 years with hip fracture who underwent open reduction and internal fixation or hemiarthroplasty for comparison with healthy controls (i.e. individuals without hip fracture). The study and comparison cohorts were matched for age, sex, and index year at a 1:4 ratio. The incidence and hazard ratios of age, sex, and multiple comorbidities associated with S-UTI were calculated using Cox proportional hazard regression models. Among the 5774 and 23,096 patients in the study and comparison cohorts, the overall incidence of S-UTI per 100 person-years was 8.5 and 5.3, respectively. The risk of S-UTI was cumulative over time and higher in the study cohort than in the comparison cohort, particularly in those who were older, were female, or had comorbidities of cerebrovascular accident or chronic renal failure.

Ultrasonographic and Radiographic Diagnosis of Ectopic Ureter in a Dog

Background: Ureteral ectopia (or ectopic ureter) is a congenital anomaly of the urinary system in which the ureter inserts anywhere other than the vesical trigone. This anatomical change may have unilateral or bilateral involvement. The most evident clinical sign, occurring mostly in females, is urinary incontinence, however in some cases the condition may progress to nephritis and dilation of the renal pelvis. The diagnosis is established through imaging, and definitive treatment requires surgical approach. The present study reports a case of ureteral ectopia in a dog which was diagnosed by ultrasound and contrast radiography (excretory urography) and successfully treated by neoureterostomy.Case: A 10-month-old female American Pit Bull Terrier was attended at the Veterinary Hospital of the Federal Rural University of the Semi-Arid (UFERSA), in Mossoró, RN. Her owner reported incontinence of dark, malodorous urine since birth as the chief complaint. After clinical examination, cystitis was suspected, and a complete blood count, urinalysis, and abdominal ultrasound was requested. The blood count and creatinine were within the reference values. The presence of struvite crystals were found on urinalysis. Ultrasound examination revealed a tortuous, dilated right ureter from the renal pelvis to the urinary bladder; no uroliths were identified as a cause of potential obstruction, but the ipsilateral kidney showed increased cortical echogenicity, loss of corticomedullary definition, and moderate pelvic dilation. These findings supported a presumptive diagnosis of ectopic ureter. For the purpose of confirming this suspicion, excretory urography was performed, revealing unilateral ureteral dilation and radiopaque contrast uptake following the path of the urethra. Once the diagnosis was confirmed, surgery was performed to correct the ureteral ectopia using the standard neoureterocistostomy technique. Considering the unilateral involvement, location of the insertion, and preserved renal function, the decision was made to perform a neoureterostomy. During the surgery it was possible to identify that the ectopic ureter was found to be intramural. At 2-month follow-up, urinary incontinence had resolved and control ultrasound showed significant improvement in the inflammatory appearance of the right renal parenchyma, with no signs of dilation of the renal pelvis or ureter.Discussion: Different from what happens in male dogs, females with an ectopic ureter will often present with urinary incontinence as the main (and, often, only) symptom, usually in the first months of life. As pollakiuria suggests a wide range of diseases of the urinary tract, ultrasound was considered the first-line imaging modality of choice, indispensable for ruling out other differential diagnoses such as a severe urinary tract infection, urolithiasis, or even malignancy. Despite the literature reporting that urinary incontinence persists in 44 to 67% of cases of ureteral ectopia, even after surgery in this case there was complete recovery of the patient after two months. Accessible techniques like ultrasonography and contrast radiography (excretory urography) supplemented one another in the elucidation of this case, with both demonstrating an excellent contribution to the diagnosis of ectopic ureter as well as served as support for surgical planning, enabling effective repair and consequent recovery of the patient.

DRUG-RELATED URINARY TRACT INFECTIONS

Bacterial urinary tract infection (UTI) is the most common infection, both in outpatient treatment and in hospital settings. Clinically, UTIs are classified into lower or upper urinary tract infections and can be either episodic or recurrent, and either uncomplicated or complicated. A severe UTI can lead to urosepsis and septic shock, while recurrent episodes of uncomplicated UTIs are considered to be an important etiological factor for the development of chronic kidney disease. The aim of this paper was to briefly discuss the classification, symptomatology and pathophysiology of a UTI and describe the rationale for the development of some drug-related urinary tract infections. The pathophysiology of a UTI is associated with multiple, anatomical and physiological dysfunctions that predispose infection, but there are also some iatrogenic factors, including the use of certain medications, that contribute to UTI development. Among drugs associated with an increased risk of UTI development one should mention immunosuppressants, agents affecting normal voiding processes and increasing the intravesical volume of residual urine, drugs promoting lithogenesis in the urinary tract with the subsequent favouring of urinary stone formation or drugs that reduce glucose reabsorption in the kidneys, causing glycosuria (“gliflozins”). Conclusions: Therefore, a UTI may also be a specific manifestation of adverse drug reactions and it should be taken into account in the monitoring and diagnosing of druginduced disorders.

Correcting hypokalaemia in a paediatric patient with Bartter syndrome through oral dose of potassium chloride intravenous solution

Bartter syndrome is a rare autosomal recessive disorder characterized by hypokalaemia. Hypokalaemia is defined as low serum potassium concentration ˂3.5 mmol/L, which may lead to arrhythmia and death if left untreated. The aim of this case report was to normalize serum potassium concentration without the need for intravenous intervention. A 5-month-old male of 2.7 kg body weight diagnosed with Bartter syndrome was admitted to the general paediatric ward with acute severe hypokalaemia and urinary tract infection. The main challenge was the inability to administer drugs through intravenous route due to compromised body size. Therefore, we shifted the route of administration to the nasogastric tube/oral route. A total of 2 mL of concentrated intravenous potassium chloride (4 mEq potassium) were dissolved in distilled water and administered through nasogastric tube. Serum potassium concentration was rapidly normalized, which culminated in patient discharge. In conclusion, shifting drug administration from intravenous to oral route in a paediatric patient with Bartter syndrome includes numerous advantages such as patient convenience, minimized risk of cannula-induced infection, and reduced nurse workload.

Biofilm formation in uropathogenic Escherichia coli strains; Relationship with virulence factors and antimicrobial resistance

Background: Urinary tract infection (UTI) is a clinical condition with characteristic symptoms, colonization and multiplication of bacteria in significant numbers. At this juncture, antimicrobial resistance in uropathogens has become one of the major concerns globally. Therefore, the present study aimed to demonstrate the biofilm formation in uropathogenic Escherichia coli strains; characterize the phenotypic & genotypic virulence factors and their relationship with antimicrobial resistance. Methods and materials: In this study, 1000 suspected UTI cases were included. Urine samples were processed for culture and antimicrobial drug susceptibility testing. Only Escherichia coli isolates were further studied for production of biofilm, ESBL and haemolysin enzymes by phenotypic methods. Virulence genes, papEF, traT & PAI were detected by multiplex PCR. Molecular confirmation & characterization of virulence genes was done by Sanger sequencing. Results: From the 1000 urine samples, 395 E. coli were isolated. Higher resistance was observed with antibiotics - ampicillin (82.53%), cefuroxime (72.41%), amoxicillin-clavulanic acid (71.90%), ceftriaxone (66.58%), ciprofloxacin (65.82%) and cefepime (57.47%). In-vitro biofilm was formed by 71.39% isolates. Biofilm-forming strains developed higher resistance towards ampicillin, cefuroxime, amoxicillin-clavulanic acid, ciprofloxacin, cefepime and ceftriaxone. Phenotypic methods detected 62.3% isolates as ESBL producers and 40.2% were β-haemolytic. Virulence gene characterization revealed presence of traT in 73.2% strains, PAI & papEF among 62.9% and 33.5% strains. ESBL & Hemolysin producing UPEC exhibited higher resistant to ampicillin, amoxicillin-clavulanic acid, aztreonam, cefriaxone, cefuroxime, cefepime, ciprofloxacin, chloramphenicol & gentamicin. Statistically proved association was seen with gene RPAI and traT with antibiotics nitrofurantoin and amikacin. All the isolates were sensitive to nitrofurantoin, piperacillin-tazobactam, and imipenem. Strains showed 99% sequence identity and no mutations were detected. Conclusion: Increase in trend of resistance was observed with antibiotics which were routinely used to treat UTI. Results indicated significant correlation between phenotypic and genotypic virulence factors and antibiotic resistance. Antibiotics nitrofurantoin, piperacillin - tazobactam, and imipenem can be effective for severe UTIs. This study concludes that expression of virulence factors by UPEC strains is responsible for increased antibiotic resistance. Hence, characterizing the UPEC strains help clinicians to reach a better therapeutic outcomes and treatment regimens in this region.

Emphysematous cystitis in a patient using immunosuppressant agents.

A 72-year-old woman presented with a 3-day history of nausea, vomiting, and fever. She had rheumatoid arthritis and was taking prednisolone (10mg), cyclosporine (150mg), and actarit (200mg) daily. Computed tomography revealed gases were detected in the bladder wall, and emphysematous cystitis was diagnosed. When an immunocompromised host is suspected of a severe urinary tract infection but lacks specific signs or symptoms such as costovertebral angle tapping pain, emphysematous cystitis should be considered.

Delayed Fever and Acute Kidney Injury in Patients with Urinary Tract Infection.

The presence of fever has long been a warning sign of severe urinary tract infection (UTI). However, we previously identified that inpatients with afebrile UTI had an increased risk of developing acute kidney injury (AKI). After expanding this cohort, 1132 inpatients with UTI diagnosed between January 2006 and April 2019 were analyzed. Overall, 159 (14%) of these patients developed AKI; bacteremia, urolithiasis, septic shock, hypertension, lower baseline renal function, marked leukocytosis, and the absence of fever were independently linked to AKI. When we further studied the cohort of inpatients with fever during hospitalization, we identified a group of “delayed fever” UTI inpatients who did not have fever as their initial presentation. Compared to patients presenting with fever at the emergency department, patients with delayed fever tended to be younger and have less frequent infection with Escherichia coli, more frequent AKI, upper tract infection, and a longer hospital stay. Despite the initial absence of fever, these patients demonstrated larger extents of elevations in both serum white blood cell counts and C-reactive protein levels. In short, besides UTI patients with lower baseline renal function that remain afebrile during their hospital stay, clinical awareness of the increased incidence of AKI in younger patients with “delayed fever” should also be noted.

A Comparison of Outcomes for Spinal Trauma Patients at Level I and Level II Centers.

Retrospective analysis of a national database. To characterize the spine trauma population, describe trauma center (TC) resources, and compare rates of outcomes between the American College of Surgeons (ACS) level I and level II centers. Each year, thousands of patients are treated for spinal trauma in the United States. Although prior analyses have explored postsurgical outcomes for patients with trauma, no study has evaluated these metrics for spinal trauma at level I and level II TCs. The ACS Trauma Quality Improvement Program was queried for all spinal trauma cases between 2013 and 2015, excluding polytrauma cases, patients discharged within 24 hours, data from TCs without a designated level, and patients transferred for treatment. Although there were similar rates of severe spine traumas (Abbreviated Injury Scale≥3) at ACS level I and level II centers (P=0.7), a greater proportion of level I patients required mechanical ventilation upon emergency department arrival (P=0.0002). Patients at level I centers suffered from higher rates of infectious complications, including severe sepsis (0.58% vs. 0.31%, P=0.02) and urinary tract infections (3.26% vs. 2.34%, P=0.0009). Intensive care unit time (1.90 vs. 1.65 days, P=0.005) and overall length of stay (8.37 days vs. 7.44 days, P<0.0001) was higher at level I TCs. Multivariate regression revealed higher adjusted overall complication rates at level II centers (odds ratio, 1.15, 95% confidence interval, 1.06-1.24; P<0.001), but no difference in mortality (odds ratio, 1.18; 95% confidence interval, 0.92-1.52; P>0.10). ACS level I TCs possess larger surgical staff and are more likely to be academic centers. Patients treated at level I centers experience fewer overall complications but have a greater incidence of infectious complications. Mortality rates are not statistically different.

Intravenous mecillinam compared with other β-lactams as targeted treatment for Escherichia coli or Klebsiella spp. bacteraemia with urinary tract focus.

Mecillinam (amdinocillin) is active against Gram-negative bacteria. Clinical data on the efficacy of IV mecillinam for severe urinary tract infections is sparse. To assess the effectiveness of targeted IV mecillinam compared with other β-lactams for bacteraemia with Escherichia coli and Klebsiella spp. and a urinary tract focus. We performed a retrospective cohort study at five university hospitals in the Capital Region of Denmark from 1 January 2012 to 31 December 2017. We used Cox proportional hazard regression to compare the primary composite endpoint (all-cause mortality or bacteraemia recurrence within 30 days) between patients treated with mecillinam versus ampicillin, cefuroxime, piperacillin/tazobactam and meropenem. We included 1129 patients in the primary analysis, of which 146 were given IV mecillinam as targeted treatment. We found no significant difference in the primary endpoint between patients treated with mecillinam versus ampicillin and cefuroxime, but found a higher risk for the primary endpoint in the piperacillin/tazobactam and meropenem groups, with adjusted HRs of 2.22 (95% CI 1.24-3.97, P < 0.01) and 2.48 (95% CI 1.04-5.93, P = 0.04), respectively, compared with mecillinam. The results of this study suggest that IV mecillinam may be a suitable targeted treatment for bacteraemia with a urinary tract focus. However, these results need confirmation by randomized controlled studies.

Virulence and resistance properties of E. coli isolated from urine samples of hospitalized patients in Rio de Janeiro, Brazil – The role of mobile genetic elements

Extraintestinal pathogenic E. coli (ExPEC) is the most frequent etiological agent of urinary tract infections (UTIs). Particular evolutionary successful lineages are associated with severe UTIs and higher incidences of multidrug resistance. Most of the resistance genes are acquired by horizontal transfer of plasmids and other mobile genetic elements (MGEs), and this process has been associated with the successful dissemination of particular lineages. Here, we identified the presence of MGEs and their role in virulence and resistance profiles of isolates obtained from the urine of hospitalized patients in Brazil. Isolates belonging to the successful evolutionary lineages of sequence type (ST) 131, ST405, and ST648 were found to be multidrug-resistant, while those belonging to ST69 and ST73 were often not. Among the ST131, ST405, and ST648 isolates with a resistant phenotype, a high number of mainly IncFII plasmids was identified. The plasmids contained resistance cassettes, and these were also found within phage-related sequences and the chromosome of the isolates. The resistance cassettes were found to harbor several resistance genes, including blaCTX-M-15. In addition, in ST131 isolates, diverse pathogenicity islands similar to those found in highly virulent ST73 isolates were detected. Also, a new genomic island associated with several virulence genes was identified in ST69 and ST131 isolates. In addition, several other MGEs present in the ST131 reference strain EC958 were identified in our isolates, most of them exclusively in ST131 isolates. In contrast, genomic islands present in this reference strain were only partially present or completely absent in our ST131 isolates. Of all isolates studied, ST73 and ST131 isolates had the most similar virulence profile. Overall, no clear association was found between the presence of specific MGEs and virulence profiles. Furthermore, the interplay between virulence and resistance by acquiring MGEs seemed to be lineage dependent. Although the acquisition of IncF plasmids, specific PAIs, GIs, and other MGEs seemed to be involved in the success of some lineages, it cannot explain the success of different lineages, also indicating other (host) factors are involved in this process. Nevertheless, the detection, identification, and surveillance of lineage-specific MGEs may be useful to monitor (new) emerging clones.

Risk of common infections among individuals with psoriasis in Sweden: A nationwide cohort study comparing secukinumab to ustekinumab.

PurposeTo determine risk of respiratory tract infections, urinary tract infections and candidiasis in secukinumab users compared to ustekinumab users among individuals with psoriasis in Sweden.MethodsThis was a Swedish population‐based register‐linked new‐user cohort study on individuals with psoriasis and psoriasis arthritis treated with secukinumab (2015‐2017) and ustekinumab (2009‐2017). Ever‐never exposure definition was used, that is, each individual's follow‐up time was attributed to the drug they were first exposed to. Risk of severe respiratory and urinary tract infections and candidiasis (diagnosis codes from out‐patient specialist visits and in‐patient hospitalisations) and respiratory and urinary tract infections treated in primary care (proxied by dispensation of antibiotics) was determined by adjusted hazard ratios (HRs) and 95% confidence intervals (CIs) using Cox regression. We also give crude incidence rates and rate ratios.ResultsIn total, 1955 new users of secukinumab (n = 848) and ustekinumab (n = 1107) were identified. There was a slightly increased risk of respiratory and urinary tract infections treated in primary care among secukinumab users compared to ustekinumab users (HR: 1.22, 95% CI: 1.03‐1.43). Non‐significant differences in estimated risk of severe respiratory and urinary tract infections (HR: 0.96, 95% CI: 0.57‐1.61) and candidiasis (HR: 1.80, 95% CI: 0.84‐3.84) treated in the hospital setting were observed.ConclusionWe observed a slightly increased risk of respiratory and urinary tract infections treated in primary care among secukinumab users compared to ustekinumab users. Larger studies with longer follow‐up are needed to draw conclusions on relative safety.

Necrotising fasciitis from fulminant pyelonephritis

AbstractEmphysematous pyelonephritis (EPN) is a severe urinary tract infection (UTI) that causes kidney necrosis by gas‐producing bacteria. Escherichia coli is most implicated. Type‐2 diabetes mellitus (T2DM) is a common predisposing factor. Necrotising fasciitis (NF) is an uncommon complication of EPN that has severe consequences. It is easily missed due to rarity. We present the case of an 82‐year‐old female nursing home resident with T2DM that presents with NF of the left flank following EPN of the left kidney that has penetrated through the superior lumbar triangle. This is the first time this anatomical pathway has been implicated in NF secondary to EPN in the English literature.

Can we treat bladder cancer with intravesical Bacillus Calmette-Guerin in patients with prior tuberculosis infection? A population-based cohort study

BackgroundIntravesical bacillus Calmette-Guerin (BCG) therapy is the treatment of choice for patients with T1 or high-grade superficial bladder cancer or those with carcinoma in situ after transurethral resection. A personal history of tuberculosis infection has been viewed as a relative contraindication for BCG therapy, because it may increase the risk of complications or decrease the treatment effectiveness. We determined the safety and efficacy of intravesical BCG treatment for patients with prior tuberculosis infection by analyzing the data obtained from the National Health Insurance Research Database in Taiwan.MethodsWe included patients who were newly diagnosed with bladder cancer from 2000 to 2009 and who received adjuvant intravesical BCG therapy within 3 months after the surgery. We excluded those who developed upper urinary tract cancer during the study period. Disease recurrence, disease progression, and major adverse effects were compared between patients with and without a prior diagnosis of tuberculosis infection until December 31, 2011.ResultsAmong the 3915 patients included, 187 (4.8%) had been previously diagnosed with tuberculosis infection. The proportion of men (84.0% versus 76.9%) and older patients was higher in the group with a prior tuberculosis infection than in those without a prior tuberculosis infection. Significant differences in disease recurrence (20.3% versus 22.8%; hazard ratio [HR], 0.87; 95% confidence interval [CI], 0.63–1.21, p = 0.404) or disease progression (10.2% versus 12.8%, HR, 0.74; 95% CI, 0.46–1.17, p = 0.191) were not observed between the two groups. None of the patients with a prior tuberculosis infection had severe urinary tract infections, whereas four (0.1%) patients without such an infection developed severe urinary tract infections.ConclusionA prior tuberculosis infection did not affect the treatment efficacy or safety of intravesical BCG treatment. The efficacy and safety of intravesical BCG therapy are comparable between bladder cancer patients with and without prior tuberculosis infections.

Predicting outcome of patients with severe urinary tract infections admitted via the emergency department.

ObjectiveTo evaluate clinical prediction tools for making decisions in patients with severe urinary tract infections (UTIs).MethodsThis was a retrospective study conducted at 2 hospitals (combined emergency department (ED) census 190,000). Study patients were admitted via the ED with acute pyelonephritis or severe sepsis‐septic shock related UTI. Area under the receiver operating characteristic curve (AUROC) augmented by decision curve analysis and sensitivity of each rule for predicting mortality and ICU admission were compared.ResultsThe AUROC of PRACTICE was greater than that of BOMBARD (0.15 difference, 95% confidence interval [CI] = 0.09–0.22), SIRS (0.21 difference, 95% CI = 0.14–0.28) and qSOFA (0.06 difference, 95% CI = 0–0.11) for predicting mortality. PRACTICE had a greater net benefit compared to BOMBARD and SIRS at all thresholds and a greater net benefit compared to qSOFA between a 1% and 10% threshold probability level for predicting mortality. PRACTICE had a greater net benefit compared to all other scores for predicting ICU admission across all threshold probabilities. A PRACTICE score >75 was more sensitive than a qSOFA score >1 (90% versus 54.3%, 35.7 difference, 95% CI = 24.5–46.9), SIRS criteria >1 (18.6 difference, 95% CI = 9.5–27.7), and a BOMBARD score >2 (12.9 difference, 95% CI = 5–12.9) for predicting mortality.ConclusionPRACTICE was more accurate than BOMBARD, SIRS, and qSOFA for predicting mortality. PRACTICE had a superior net benefit at most thresholds compared to other scores for predicting mortality and ICU admissions.

Case Report: Recurrent Pyometra in an Adolescent

Pyometra is an uncommon but serious condition that is generally diagnosed in postmenopausal women. It rarely occurs in premenopausal patients, particularly adolescents. A 16-year-old girl with multiple comorbidities including severe intellectual disability, neurogenic bladder, and recurrent urinary tract infection presented with fever, abdominal pain, and vaginal discharge after prolonged treatment with depot medroxyprogesterone acetate. Ultrasound imaging showed an intrauterine fluid collection consistent with hematometra; however, hysteroscopic evaluation confirmed pyometra, which was evacuated using a suction curette. Despite postoperative antibiotic therapy, she re-presented with similar findings requiring additional hysteroscopic evaluation and evacuation. After a third evacuation, an intrauterine catheter was placed to aid in drainage. This was not tolerated by the patient, and she ultimately required total laparoscopic hysterectomy for definitive management, which was performed without incident. Pyometra is a rare occurrence that typically presents after menopause; however, it should be considered in patients with poor genitourinary hygiene and medically induced endometrial atrophy. In severe cases, hysterectomy might be required for definitive management.

A prospective Comparative Clinical Study on Bladder Urine, Pelvic Urine and Renal Stone Culture &amp; Sensitivity in Predicting Urosepsis Following Percutaneous Nephrolithotomy

Background: Urosepsis means a severe infection of urinary tract (UTI) and/or male genital tract (prostate) with features consistent with systemic inflammatory response syndrome. UTI may occur among all the age groups and produce a broad range of clinical syndromes ranging from asymptomatic bacteriuria to acute pyelonephritis with gram negative sepsis to septic shock. It is estimated that the mortality rate due to urosepsis ranges from 30 to 40 p.c respectively. Urosepsis may also cause multiple organ dysfunction, hypoperfusion or hypotension. Urosepsis due to percutaneous nephrolithotomy may be catastrophic despite prophylactic antibiotic coverage and negative midstream urine culture and sensitivity testing (C&amp;S) and bacteria in the stone can be responsible for systemic infection. The aim of the study is to compare bladder urine (culture &amp; sensitivity) and collecting system urine and stone (culture and sensitivity) in predicting urosepsis following percutaneous nephrolithotomy. Subjects and Methods: A hospital-based, analytical prospective clinical study was conducted among thirty cases who were present during the study period and had undergone percutaneous nephrolithotomy (PCNL). Cases were included irrespective of gender with renal calculi in whom percutaneous nephrolithotomy was about to be done at Narayana Medical College &amp; Hospital, Chintareddypalem, Nellore, Andhra Pradesh during 1st February 2014 to 31st January 2015. Data collected was divided into three main groups Midstream urine (C&amp;S); Pelvic urine (C&amp;S); and Stone (C&amp;S) respectively. Data obtained was entered in Microsoft Excel-2013 and analyzed in SPSS version-22 trial. Appropriate statistical tests were applied and p-value less than 0.05 was considered as significant. Results: Bladder urine (C&amp;S) was positive in 3/30 (10.00%) patients, Pelvic urine (C&amp;S) in 5/30 (16.66 %) patients and Stone (C&amp;S) in 8/30 (26.66 %) patients. Most of the infected specimens grew Escherichia coli followed by pseudomonas, klebsiella, enterococcus. Systemic Inflammatory Response Syndrome (SIRS) was reported among 26.7 p.c (8) of the patients. In one patient (3.33%) septic shock developed but no deaths were reported. Conclusion: Stone (C&amp;S) and Pelvic urine (C&amp;S) are better predictors of urosepsis than Bladder urine (C&amp;S).