Symptoms Of Pyelonephritis Research Articles

#1150 Neutrophil rich infiltrate in immunotherapy induced acute interstitial nephritis

Abstract Background and Aims Acute interstitial nephritis (AIN) is a well-recognized cause of acute kidney injury (AKI) in patients treated with Immune checkpoint inhibitors (ICI). Kidney biopsy typically shows tubular interstitial infiltration with well-differentiated mononuclear cells with occasional granulomas and eosinophils. Neutrophil rich tubular interstitial infiltration is typically associated with pyelonephritis. We report a case series of neutrophil rich ICI induced AIN. Method After obtaining approval from the institutional review board, medical records of the nephrology service at a large cancer center were reviewed. Patients were included in the study if they underwent a kidney biopsy for the diagnosis of ICI associated AKI, the biopsy was consistent with atypical AIN with neutrophil rich infiltrate, there was no glomerular involvement, they exhibited no symptoms of pyelonephritis including but not limited to fever, nausea, vomiting, flank pain and dysuria and had a negative urine culture. Results Forty eight patients who had a biopsy proven ICI associated AIN were identified from the medical records. Four (8.3%) patients met the study criteria (Table 1). There were three males and one female. The mean age was 75.5 years. One patient had a history of pre-existing CKD stage 3. Mean number of ICI therapy cycles prior to the development of AIN was seven with two patients treated with pembrolizumab (2 and 14 cycles), one patient treated with nivolumab (1 cycle) and one patient treated with the combination of nivolumab and ipilimumab (2 cycles). All patients presented with asymptomatic rise in serum creatinine (sCr). Kidney biopsy showed neutrophil rich infiltrate and neutrophilic tubulitis in all patients. Neutrophilic casts were present in three biopsies. One patient had evidence of granulomatous inflammation. All patients had mild to moderate interstitial fibrosis. Three patients were initially treated with flat dose prednisone 60 mg daily and one was treated with weight adjusted dose of prednisone 1 mg/kg at 75 mg/day. Three patients had complete renal recovery (sCr < 0.5 mg/dl above baseline) after steroid taper. One patient developed a relapse but achieved partial recovery (sCr < 2x baseline) after the second taper. Two patients remain alive three and 12 months after the kidney biopsy. Two patients died due to the progression of cancer two and 10 months after the biopsy. Conclusion AIN with neutrophil rich infiltrate likely represents a subset of ICI induced AIN. In the absence of clinical signs of pyelonephritis and with evidence of negative urine cultures the treatment should be geared towards addressing inflammation with systemic corticosteroids which have been shown to be effective in management of ICU induced AIN. Avoidance of antibiotics in this setting would lead to better antibiotic stewardship.

Assessment of Urinary and Serum Neutrophil Gelatinase-Associated Lipocalin (NGAL) Levels as Novel Predictors for Vesicoureteral Reflux Diagnosis in Children with Febrile Urinary Tract Infection.

The invasive, expensive, and time-consuming nature of radiological examinations for vesicoureteral reflux (VUR) has compelled researchers to search for new markers to predict VUR. This study was designed to evaluate the usefulness of serum and urine concentrations of neutrophil gelatinase-associated lipocalin (NGAL) in predicting the existence of VUR. This cross-sectional study involved all patients with a first febrile urinary tract infection (UTI) referred to Ali Asghar Children's Hospital. Each patient included in the study had clinical symptoms of pyelonephritis and a positive urine culture. The patients were divided into 2 groups: VUR and non-VUR. The serum and urinary NGAL levels were calculated in both groups. The receiver operating characteristic (ROC) curve was used to look for serum and urinary NGAL cut-points that differentiated the VUR group from the non-VUR group. Among the 40 children in the study, 23 belonged to the VUR group. The median age was 2.5 years (range, 0.3-8 years), and 35 patients were girls. ROC curve analysis showed that only the urinary NGAL level was significantly related to VUR. There was no association between serum NGAL levels and VUR. According to the ROC curve, a urinary NGAL level cut-off value of 15 ng/mL was likely to be diagnostic of VUR with 82.6% sensitivity and 58.8% specificity. The urinary NGAL level, specifically with a cut-off value of 15 ng/mL, can indicate the existence of VUR in patients with UTI with near-acceptable levels of sensitivity and specificity.

Pyelonephritis due to Escherichia coli in the older population in Japan: Impacts on activities of daily living and medical costs.

This study aimed to investigate differences in Activities of Daily Living (ADL), at admission and discharge, as well as the medical costs of pyelonephritis in older adults in Japan. Patients hospitalized for pyelonephritis between January 1, 2013 and March 31, 2019, were retrospectively enrolled. The inclusion criteria were urine culture within 48 h of admission with > 104 colony-forming units/mL of Escherichia coli and symptoms of pyelonephritis. Patients were divided into Young (20-64 years), Pre-old (65-74 years), Old (75-84 years), and Super-old (≥ 85 years). ADL and medical costs were compared. Finally, 393 patients were included: 112 (28.5%) were Young, 72 (18.3%) were Pre-old, 130 (33.1 %) were Old, and 79 (20.1%) were Super-old between January 1, 2013, and March 31, 2019. The median differences between Barthel Index (BI) scores, which indicates ADL, at admission and discharge were 0, 0, 25, and 23 in each age group, respectively (p < 0.001). No significant differences existed between the groups aged ≥ 65. Median medical costs were $3,368, $4,894, $5,372, and $6,078 for each age group, respectively (p < 0.001). Medical costs per day did not differ significantly between the groups (p = 0.163). Pyelonephritis due to E. coli in patients aged ≥ 75 is associated with a decline in ADL, longer hospital stays, and higher medical costs compared to that in young patients. Pre-old patients did not have lower ADL; however, they tended to have longer hospital stays and higher medical costs.

Recurrent Urinary Tract Infection in Women from a Urologist’s Perspective

Urinary tract infection (UTI) referred to microbial invasion of the urinary tract system, typically due to bacteria. UTI is more common in women than men, which is thought to be due to differences in lower urinary tract anatomy. Making a diagnosis of UTI begins with the presence of clinical symptoms consistent with either pyelonephritis and cystitis. When pyelonephritis symptoms are present, it is usually associated with bacterial infection, while the symptoms of clinical cystitis may or may not be caused by infection. As both urologic and non-urologic conditions can produce the clinical symptoms of cystitis, diagnosis of UTI requires both pyuria and bacteriuria on urine examination. Complicated UTI is when the infection is associated with either host or bacterial factors that increase the chance of reinfection and decrease treatment efficacy, such as altered organism virulence, immunocompromise, or urinary tract abnormalities. The urologist’s primary role in UTI management is to evaluate for such urinary tract abnormalities and, if needed, resolve those conditions to prevent recurrent infection. This review will describe the urologists’ evaluation and management of complicated and recurrent UTI and inform physician about the urinary tract abnormalities that can predispose to recurrent UTI.

Prior cultures predict subsequent susceptibility in patients with recurrent urinary tract infections

Background: Patients with recurrent urinary tract infections (rUTI) experience frequent exposure to antimicrobial regimens, leaving them at higher risk for developing antibiotic resistance. Little information on the prevalence of antibiotic resistance among patients with rUTI has been published. Although the IDSA recommends using a prior culture to guide empiric treatment, studies have not examined the predictive ability of a prior culture among patients meeting rUTI criteria. We constructed an antibiogram and evaluated test metrics, including sensitivity, specificity, and positive predictive value (PPV) and negative predictive values (NPV) of a prior culture (any organism), on predicting resistance (PPV) or susceptibility (NPV) of a future culture among patients with uncomplicated rUTI in an outpatient setting. Methods: We retrospectively extracted electronic health record data from outpatients aged ≥18 years who had an ICD-10 code for cystitis listed twice in 6 months or thrice in 12 months between November 1, 2016, and December 31, 2018. Patients sought care at either urology or primary care practices within an academic medical center in Houston, Texas. Patients with functional or structural abnormalities of the genitourinary tract, signs or symptoms of pyelonephritis, or pregnancy were excluded. Antibiogram data were reported for uropathogens with ≥30 isolates, and intermediate results were considered resistant. Test metrics and Bayes’ PPV and NPV were calculated using standard formulas. Results: We included 597 visits from 232 unique patients. Most were White (63%) and female (92%), and the cohort had a median age of 58 (IQR, 41–68). Among 310 rUTI episodes with a urine culture, 189 (61%) had at least 1 uropathogen isolated, and Escherichia coli (n = 130, 66%) was most common among all 196 uropathogens. E. coli isolates had &gt;20% resistance to 10 of 18 antibiotics (Fig. 1). E. coli resistance to ciprofloxacin was 27.9%, resistance to nitrofurantoin was 5.5%, and resistance to trimethoprim-sulfamethoxazole was 38.0%. The PPVs for predicting resistance were highest for ceftriaxone (0.86; 95% CI, 0.60–0.96), ciprofloxacin (0.84; 95% CI, 0.63–0.94), and levofloxacin (0.84; 95% CI, 0.63–0.94). NPVs of resistance were highest for gentamicin (0.97; 95% CI, 0.83–1.00), ceftriaxone (0.94; 95% CI, 0.86–0.98), and cefepime (0.94; 95% CI, 0.84–0.98), whereas NPVs for cefuroxime, ciprofloxacin, levofloxacin, and nitrofurantoin were all &gt;0.83. Conclusions: We detected considerable antibiotic resistance among patients with rUTI to commonly prescribed antibiotics. Prior urine culture susceptibility demonstrated moderate-to-high PPVs for predicting future resistance to ceftriaxone and fluoroquinolones as well as high NPVs for several cephalosporins and fluoroquinolones, which could inform empiric prescribing choices.Funding: This investigator-initiated research study was funded by Rebiotix, a Ferring Company.Disclosures: None

Outcome of post-COVID-19 fungal pyelonephritis: A single Indian tertiary center experience.

Introduction:COVID-19 pandemic is associated with secondary opportunistic fungal infections. These have an aggressive course with a high mortality rate. We present our experience of seven cases of post-COVID-19 fungal pyelonephritis.Methods:An observational study over a period of 8 months of May to December 2021 was carried out at our tertiary care hospital, including all patients with features of fungal pyelonephritis in post-COVID-19 setting. The patient demographics, details of previous COVID-19 infection, details of present admission and management were collected. The endpoints were either discharge from the hospital or death.Results:Seven patients were included. Mean age of presentation was 42 years (range: 20–63 years, standard deviation ± 14.2). Male-to-female ratio was 6:1. One patient was diabetic. Two patients were asymptomatic, one had mild infection, and four patients had severe COVID-19 infection as per National Institute of Health criteria. In the present admission, all patients had symptomatic pyelonephritis with laboratory parameters showing elevated D dimer, C reactive protein, and total leukocyte counts. In all seven patients, ultrasound of kidney ureter bladder region showed bulky kidney, color Doppler showed main renal arterial thrombosis in two patients, segmental arterial thrombosis in another patient. Computed tomography scan was suggestive of changes of pyelonephritis in all patients with multiple renal hypodense areas. All patients required nephrectomy with biopsy suggestive of changes of necrotizing fungal inflammation. Three patients expired.Conclusion:Management of post-COVID-19 fungal pyelonephritis should be aggressive and suspicious laboratory and imaging findings should be treated by early nephrectomy.

Listeria monocytogenes infection during pregnancy

Listeria monocytogenes is an important pathogenic bacteria found in soil or water being the causative agent of listeriosis, a severe foodborne disease during pregnancy. The outcome can lead up to miscarriage, stillbirth, preterm birth and congenital neonatal infections, under occult or overt illness of the mother. We performed a literature review in the medical database PubMed, searching relevant information regarding listeriosis during pregnancy and neonatal outcome. Higher incidences were observed in ethnic minorities, as a reflection of specific dietary habits and where surveillance is not thoroughly implemented. Also, the infection was most commonly seen during the second or third trimester of pregnancy, with maternal presentation under the form of flu-like or pyelonephritis symptoms, or even asymptomatic. Regarding the neonatal infection, there are two types described according to the way of acquiring the bacteria. The obstetric outcome ranges from premature delivery to miscarriage and stillbirth. Treatment of choice is a combination of ampicillin and aminoglycoside. Despite the advances in the field of infectious diseases, challenges remain to completely understand the mechanism of placental invasion of Listeria monocytogenes and the severe consequences on fetal development.

Analysis of Recurrent Urinary Tract Infection Management in Outpatient Settings Reveals Opportunities for Antibiotic Stewards

Background: Studies of antibiotic prescribing choice and duration have typically excluded women with recurrent UTI (rUTI), yet the Infectious Disease Society of America (IDSA) UTI treatment guidelines are applicable to recurrent and sporadic cystitis. We sought to better understand prescribing practices among uncomplicated rUTI patients in terms of choice of drug, duration of therapy, and the risk factors for receiving guideline-discordant therapy. Methods: We performed a retrospective database study by extracting electronic health record data from adults seen at academic primary care, internal medicine, or urology practices between November 2016 and December 2018. Inclusion criteria included having ≥2 or ≥3 International Classification of Diseases Tenth Edition (ICD-10) cystitis codes recorded within a 6- or 12-month period, respectively. We excluded patients with ICD-10 codes indicating any structural or functional genitourinary comorbidities, interstitial cystitis, vaginosis, compromised immune systems, or pregnancy in the prior year. Patients were also excluded if they had signs or symptoms of pyelonephritis at presentation. Results: Overall, 232 patients presented for 597 outpatient visits. Most were married (52.2%), non-Hispanic white (62.9%), and female (92.2%), with a median age of 58 years (IQR, 41–68). Only 21% of visits with an antibiotic prescribed for treatment consisted of a first-line therapy agent prescribed for the recommended duration. In terms of antibiotic choice, these agents were prescribed in 58.4% of scenarios, which primarily included nitrofurantoin (37.8%) and trimethoprim-sulfamethoxazole (TMP-SMX) (20.3%). Guideline-discordant choices of fluoroquinolones (28.8%), and β-lactams (11.2%) were the second and third most commonly prescribed drug categories, respectively. Multinomial logistic regression identified age (OR, 1.02; 95% CI, 1.002–1.04) or having a telephone visit (OR, 3.17; 95% CI, 1.54–6.52) as independent risk factors for receiving a β-lactam. The duration exceeded the 3-day guideline recommendation in 87.6% of fluoroquinolones and 73% of TMP-SMX (73%) prescriptions, and 61% of nitrofurantoin prescriptions exceeded the recommended 5-day duration. Multiple logistic regression analysis revealed that seeking care at a urology clinic (OR, 2.81; 95% CI, 1.59–5.17) served as an independent factor for therapy duration exceeding guideline recommendations. Conclusions: This retrospective study revealed shortcomings in prescribing practices in the type and duration of therapy for rUTI. rUTI as well as sporadic UTI are important targets for outpatient antibiotic stewardship interventions.Funding: This investigator-initiated research study was funded by Rebiotix Inc, a Ferring Company.Disclosures: None

Retrospective Study on Hospital Admissions due to Pyelonephritis in Type II Diabetic Patients

Background: Pyelonephritis is a urinary tract infection that ascends to involve the kidneys. It can also occur as an infection secondary to bacteremia. Some pathogens that commonly cause pyelonephritis are E. coli, enterobacteriaceae, staphylococci, and pseudomonas. The initial patient presentation usually involves fever, chills, nausea, vomiting, costovertebral angle tenderness, and flank pain. Other cystitis symptoms such as dysuria, increased urinary frequency, malodorous urine, and hematuria may or may not be present. Symptoms of pyelonephritis with bacteriuria are sufficient for the diagnosis of pyelonephritis. Aim: The aim of this study was to investigate a potential link between Type II Diabetes Mellitus and pyelonephritis. Methods: In this retrospective study, hospitalized patients during the study period were reviewed. Variables examined were sex, age, and length of stay. Patients were excluded if they had known urogenital abnormalities, indwelling catheters (Foley, nephrostomy, suprapubic, or who regularly perform clean intermittent catheterization), were pregnant, or were on dialysis. Results: Of 333 patients analyzed, diabetics had a longer length of stay then non-diabetics (4.49 vs 3.67 days respectively; p=0.0041) and females were significantly younger than men in hospitalized patients for pyelonephritis were (50.0 vs 63.5 years; p=&lt;0.0001). Further, it was found that diabetics were significantly older than nondiabetics were (60.4 vs 47.3; p=&lt;0.0001) and more diabetics getting admitted with pyelonephritis were men vs women (59.32% vs 35.27%; p=0.0007). Conclusion: Results of the study were significant in showing that of all pyelonephritis-hospitalized patients on average the length of stay was longer for diabetics and it demonstrated that female patients with pyelonephritis are significantly younger than male patients hospitalized with pyelonephritis. Of note, there was no significant difference in the length of stay for diabetic patients based on their treatment modality (diet controlled vs. oral medications vs. insulin dependent vs. combined). The study also showed that diabetics getting admitted for pyelonephritis are more men and older in age compared to the nondiabetics.

Renal Tuberculosis Presented as Emphysematous Pyelonephritis: A Case Report

Emphysematous pyelonephritis(EPN) is an acute necrotic infection of the kidney which is characterized by presence gas in the renal parenchyma. Uncontrolled diabetes mellitus and obstruction of the urinary tract are the main predisposing factors and Mycobacterium tuberculosis is a rare causative pathogen. One of the major health problem faced particularly by the developing world since ages is that of tuberculosis (TB). Genitourinary tuberculosis (GUTB) is the second most common extra-pulmonary TB, with kidney being the most frequent site of infection. We herein report a case of a patient with uncontrolled diabetes mellitus who was admitted through emergency department with symptoms of pyelonephritis. Imaging revealed the gas in the renal parenchyma establishing the diagnosis and as we found sterile pyurea we searched for Mycobacterium tuberculosis. GUTB was diagnosed and was treated successfully with anti TB drugs. EPN is a medical emergency and once diagnosed, attention must be paid to avoid high mortality rates.&#x0D; Anwer Khan Modern Medical College Journal Vol. 11, No. 1: Jan 2020, P 73-77

Current Management of Urinary Tract Infection and Vesicoureteral Reflux.

Urinary tract infection (UTI) is defined as the growth of a significant number of microorganisms of a single species in the urine, in the presence of symptoms. Symptoms in young children are non-specific such as fever without focus; young infants may manifest with irritability, failure to thrive, jaundice, vomiting and diarrhea. Older children usually have symptoms of cystitis or pyelonephritis. Symptoms of cystitis are dysuria, frequency, new onset incontinence and malodorous urine while symptoms of pyelonephritis are high grade fever, flank pain and vomiting. Rapid urine testing by microscopy for pus cells, dipstick testing for leukocyte esterase and nitrite, and enhanced urinalysis are supportive tests. Urine culture samples should be collected with proper technique and results interpreted for significant growth accordingly. Antibiotic therapy for 7-14 d for complicated UTI and 3-4d for uncomplicated UTI is adequate. Further evaluation is recommended clinically for bladder-bowel dysfunction and obvious anatomical defects and by imaging for vesicoureteral reflux (VUR), usually by micturating cystourethrography (MCU). Since MCU involves exposure to radiation and urethral catheterization, it is now reserved for children with parenchymal involvement or recurrent UTI. VUR is the backward flow of urine into one or both ureters. Clinical manifestations other than UTI include incidental diagnosis on antenatal ultrasonography. Reflux nephropathy, the renal scarring associated with VUR may manifest clinically as hypertension, proteinuria and renal failure. The management of VUR is primarily with antibiotic prophylaxis. Anatomical correction is indicated in case of breakthrough febrile UTI. No intervention has been shown to reduce renal scarring.

Investigating the Effect of Montelukast on the Pyelonephritis Symptoms in Children

BackgroundMontelukast as an anti-inflammatory drug has a protective effect on the kidney’s tissue and also on children with pyelonephritis.ObjectivesTherefore, this study aimed at investigating the effect of montelukast on the pyelonephritis symptoms in children.MethodsIn this study, 100 children with pyelonephritis were divided into two groups, including the intervention (n = 50) and control (n = 50) groups. Patients in both groups received routine antibiotic therapy and in the intervention group, montelukast (5 mg/day, oral) was prescribed (for 14 days). Finally, the clinical manifestations of the patients were evaluated and compared between two groups.ResultsThe mean age (± SD) in intervention and control groups was 7.2 (± 0.43) and 7.18 (± 0.43) years, respectively. Analysis of the results showed that the duration of fever (P < 0.0001), dysuria (P < 0.0001), abdominal pain (P < 0.0001) and urgency (P = 0.003) were significantly lower in the intervention group than the control group.ConclusionsMontelukast lead to rapid improvement of clinical manifestations in children with pyelonephritis and may can be used as an effective auxiliary treatment in these patients.

Renal pyelocalyceal squamous cell carcinoma in a patient with an ectopic kidney presenting with chronic pyelonephritis: a case report

BackgroundUntil now, few cases of pelvis squamous cell carcinoma in various renal anomalies have been reported. To our knowledge, primary squamous cell carcinoma arising from a pelvic ectopic kidney has never been described. In this report, we describe a case of renal pyelocalyceal squamous cell carcinoma in a patient with an ectopic kidney presenting with chronic pyelonephritis.Case summaryA 73-year-old Caucasian woman presented to our hospital with pyelonephritis symptoms. Abdominopelvic computed tomography revealed heterogeneous and irregular minimal contrast enhancement in the pelvic ectopic kidney parenchyma. Radiologists reported that the images were consistent with chronic pyelonephritis. A Tc-99m dimercaptosuccinic acid renal scan demonstrated a nonfunctioning right pelvic ectopic kidney. The patient underwent open simple nephrectomy via modified Gibson incision. The whole mass was a distended, saclike structure without any grossly visible renal tissue. Pathological examination showed renal pelvis squamous cell carcinoma 8 cm in diameter infiltrating into the renal capsule and perinephritic fatty tissue. The patient was staged as T4N0M1 renal pelvis squamous cell carcinoma. The patient was being treated in the intensive care unit for respiratory distress on the seventh day after the operation. By the first-month follow-up visit, the patient had died of acute respiratory distress syndrome.ConclusionsAlthough rare, renal pelvis squamous cell carcinoma should be considered in the differential diagnosis of a renal mass in patients who have renal anomalies and chronic pyelonephritis.

Study of clinical etiological and radiological profile of UTI cases

Background: Fever and significant bacteriuria and pyuria in children with undocumented sources of infections must be presumed to be symptoms of pyelonephritis, an invasive infection of the renal parenchyma requiring prompt treatment. The present study is undertaken to study of clinical, etiological and radiological profile of children with culture positive UTI.Methods: This study is being performed on children with culture positive Urinary tract infection admitted or attending OPD at department of Paediatrics during the study duration were included in the present study.Results: The highest incidence of UTI in present study was found to be 52.25% in the age group of children below 2 years. E-coli (75%) was the commonest organism found in urine culture in all age groups. Sensitivity, negative predictive value and positive predictive value of renal ultrasonography in detecting VUR was very poor, supporting the impression that renal USG is deficient in accurately excluding VUR. VUR are common in Culture positive UTI, milder grade are more common which are more likely to be missed by renal USG, thus stressing the need of MCU in children of culture positive UTI.Conclusions: Urine examination and culture and sensitivity must be a part and partial in evaluating child with fever without focus. As the scope of USG in detecting VUR is low, MCU must be done in all cases of UTI -5years irrespective of USG finding.

POLA BAKTERI DAN TES KEPEKAAN ANTIBIOTIKA WANITA HAMIL DENGAN BAKTERIURIA ASIMTOMATIS

Asymptomatic bacteriuria is defined as bacteriuria consisting of one type of bacteria ³ 105 CFU/mL in clean-voided midstreamculture of a person without any symptoms of urinary tract infection. Untreated asymptomatic bacteriuria is dangerous for pregnancybecause complications such as pyelonephritis, maternal sepsis, premature birth, and premature rupture of the membrane, low birthweight baby, hypertension and or preeclampsia, anaemia in pregnancy, amnionitis and post delivery endometriosis can arise. Someasymptomatic cases could threaten the pregnant woman and her foetus without prior pyelonephritis symptoms. The purpose of this studywas to determine the pattern of bacteria in asymptomatic bacteriuria pregnant women and their antibiotic sensitivity. This study hasbeen carried out between October 2003 and April 2004 on 376 pregnant women without symptoms of urinary tract infection. Screeningwas performed using urine culture, followed by antibiotic susceptibility test. The study showed that the prevalence of asymptomaticbacteriuria among pregnant women in RSU Dr. Soetomo was 9.85% (37 out of 376 pregnant women without urinary tract infection).Thirteen bacterial types were found in those 37 positive samples. The most common bacteria found was Escherichia coli (37.83%). Thisbacterium was sensitive to ceftriaxone (85.71%), nitrofurantoin (64.28%) and amoxicillin-clavulanic acid (57.14%). Based on the datagained in this study, it is concluded that the prevalence of pregnancy cases with asymptomatic bacteriuria in the Dr. Soetomo Hospitalis significantly high (9.85%). The most recommended drugs are ceftriaxone, amoxicillin-clavulanic acid and nitrofurantoin.

Acute Pyelonephritis - Correlation of Clinical Parameter with Radiological Imaging Abnormalities.

Pyelonephritis (PN) is a suppurative infection of the kidney, most commonly due to bacterial infection and may be either acute or chronic. Acute PN (APN) subdivided into uncomplicated and complicated. Severity of PN cannot be assessed by clinical or laboratorial parameters alone, radiological imaging such as Ultrasound (USG) abdomen, Computed Tomography (CT) is required to know the nature, extent and severity of disease and for planning interventions. The aim of this study was to compare clinical and biochemical parameters with radiological findings (USG/CT) among patients diagnosed to have PN. The medical records of all patients admitted with PN at the Institute of Nephrourology, Bangalore from January 2016 to December 2016 were reviewed. Their clinical and biochemical parameter were compared with radiological findings. Statistical analysis was performed with Statistical Package for the Social Sciences (SPSS) Version 15.0. There were 100 patients diagnosed with PN in the study period. Mean age of patient was 48.7 years and PN was common among females (62%). Classical triad of PN was present in 87% of patients. Acute kidney injury was present in 47% of patients. Diabetes (69%) was the most common comorbid condition. Positive urine culture was found in 24% of patients. USG abdomen was performed in all patients and it was suggestive of APN in 66% cases. CT abdomen was available for 74% and it revealed PN in 70%, of patients. Among these Emphysematous PN (EPN) was found in 4% and renal abscess in 3% of patients. In this study, USG findings of PN were correlated with triad of PN symptoms and those who had PN for the first time. In this study, majority of the patients presented with clinical triad of PN-fever, flank pain and dysuria. Urine culture was positive only in few cases. USG was able to diagnose large number of PN cases except emphysematous change and renal abscess which was detected by CT. The detection of PN was better with CT when compared to USG.

Intestinal Colonization Resistance and the Cytokine Response Associated with Hyperoxaluria in the Patients with Recurrent Pyelonephritis

Introduction and Aims: Hyperoxaluria and the violation of intestinal colonization resistance can be trigger factors in the formation of recurrent pyelonephritis. The aim of our study was to investigate the intestinal colonization resistance and the serum cytokines concentration in the patients with recurrent pyelonephritis depending on the presence of hyperoxaluria. Materials and Methods: The observational cross-sectional study involved 70 women with recurrent pyelonephritis caused by E. coli or S. faecalis, non-stone formers. The state of the patients’ intestinal colonization resistance was evaluated by bacteriological study of feces, determination of secretory IgA (sIg A) and IgA against lipopolysaccharide (LPS) of gramnegative bacteria in saliva and levels of interleukins (IL) -4 - 17, -23 and monocytic chemotactic protein-1 (MCP-1) in the serum. According to the presence of hyperoxaluria, the women were allocated into two groups: the first group of the patients (n = 38) had hyperoxaluria (&gt; 44mg in 24 hours) and the second one (n = 32) didn’t have any hyperoxaluria. The samples of faces had been collecting during the presence of clinical symptoms of pyelonephritis before starting the antibiotic therapy. The cytokines concentrations were analyzed using ELISA and STAT FAX-303 PLUS (Diaclon, France; DRG, Germany; Ukrmedservice, Ukraine). All the statistical analyses were performed using MedCalc. Results: Microbiological studies of the colon microflora showed a lower content of Lactobacillus spp. in 53/70 (76%) in the patients with recurrent pyelonephritis. The blood levels of IL-4, IL-17, IL-23 and MCP-1 in the women with hyperoxaluria were significantly higher compared with the non-hyperoxaluria patients: 62.2 [52.8-74.1] vs 44.5 [35.8-67] pg/ml (P=0.019), and 130.7 [101.3-231.2] vs 103.4 [77.5-133.9] (P=0.03), 123.2±17.1 vs 80.98±29.4 (P=0.03) and 325.2 [211-500] vs 121.4 [104-107.8] (P=0.0003), respectively. The saliva levels of sIg A and IgA against LPS were significantly higher in patients of the first group: 298 ± 104 vs 150.1 ± 79.3 (P&lt;0.0001) and 0.353 ± 0.16 vs 0,211 ± 0.09 respectively. In addition, we identified a moderate direct correlation between the blood level of IL-17 in the patients with recurrent pyelonephritis and daily excretion of oxalate: R=0.54, P=0.03. Conclusions: The deficit of Lactobacillus spp. violates the immune response and oxalate metabolism with formation of hyperoxaluria. The blood cytokines concentration in the patients with recurrent pyelonephritis and hyperoxaluria has not been scrutinized before. The further studies are needed to determine the role of these cytokines in the progression of urolithiasis in hyperoxaluric conditions.

Mainz II Pouch for Urinary Diversion: Outcome and Quality of Life among Patients who Underwent it at CCBRT Hospital Dar Es Salaam 2011/2013

Introduction:Obstetric fistula is the result of prolonged, obstructed labor. Each year 50,000-100,000 women affected worldwide. An estimated 2 million women live with untreated fistula in Sub-Saharan Africa and Asia. Approximately 3,700 new cases of obstetric fistula occur in Tanzania yearly but, only about 1,000 get treated. CCBRT is a specialized hospital & biggest center for obstetric fistula in Tanzania with the main objective to treat and attain continence to these patients. Rationale: Different forms of urinary diversions exist, each with its own advantages & disadvantages. MAINZ II pouch involves a permanent lifestyle change in normal micturition habit, though it’s associated with acidosis, night time incontinence, pyelonephritis and malignancies. Objectives: Assessing the outcome with emphasis on the complications and quality of life of patients who underwent MAINZ II pouch urinary diversion at CCBRT hospital during 2011-13. Methods: Inclusion criteria:Patients who consented and underwent the procedure. Followed up:Physical visits and phone calls, Documentation:Checklist designed to fill-in the variables of interest. Duration:6 to 24 months post-surgery. Results: 10 patients were followed up effectively, 7 out of 10 (70%) were completely continent through day and night. 2 (20%) were incontinent during the night 1 (10%) was incontinent through day and night 2 patients experienced recurrent flank pain with fever and responding to antibiotics. 8 (80%) had no symptoms of pyelonephritis. 90% of patients resumed full daily physical activities with improved social life. Socialization improved for those with incontinency as it’s less severe compared to pre-operatively. Conclusion: MAINZE II procedure demonstrated good outcome in terms of continence, less complications resulting improved quality of life to patients. Recommendations: Procedure recommended to patients with irreparable obstetric fistula.

Ileal Orthotopic Bladder Replacement without Stenting of the Ureterointestinal Anastomosis-10 Years Observation

Background: Stenting of ureterointestinal anastomosis is a standard precautionary measure, irrespective of the method of constructing the anastomosis; however no convincing scientific data exists to support this procedure. Objective: Clinical assessment of patients -radical cystectomy and ileal orthotopic bladder replacement without requirement for stenting of the ureterointestinal anastomosis or suprapubic cystostomy. Design, Setting, and Participants: To establish feasibility of ureterointestinal anastomosis without stenting. 426 radical cystectomies were performed between 1999 and 2009. Intervention(s): Ileal orthotopic bladder replacement with afferent loop was performed in 124 patients. Measurements: The following were evaluated: frequency of postoperative symptomatic urinary tract infections, duration of peritoneal drainage, length of hospitalization, duration of surgery, number of ureteral strictures type and number of major perioperative complications. Results and Limitations: Symptomatic pyelonephritis was observed in 10 patients (8%). The mean surgical time was 6.0 hours (4.5-9.0). The mean time of peritoneal drainage was 9.1 days (3 -40). The mean time of hospitalization was 14.1 days (7-40). Ureterointestinal anastomosis strictures were observed in 7 patients (5.6%). Major postoperative complications were observed in 12 patients (9.7%). Limitations: This is retrospective study without the control group.

Can more urological deaths in spina bifida be prevented?

This commentary is on the original article by Oakeshott et al. on pages 634–638 of this issue.