Urinary Tract Infection Group Research Articles

A pilot randomized double‐blind placebo‐controlled trial on the use of antibiotics on urinary catheter removal to reduce the rate of urinary tract infection: the pitfalls of ciprofloxacin

To assess if a short course of antibiotics starting at the time of the removing a short-term urethral catheter decreases the incidence of subsequent urinary tract infection (UTI). Patients across specialities with a urethral catheter in situ for >/= 48 h and </= 7 days were recruited at the time of catheter removal. Patients were excluded if they had had recent genitourinary surgery or were on antibiotics. Eligible patients were randomly assigned to a 48-h course of either ciprofloxacin or placebo tablets starting 2 h before catheter removal. A catheter specimen of urine was obtained before the start of the trial medication. The follow-up was at 7 and 14 days after catheter removal, with a questionnaire for UTI symptoms, and a mid-stream urine sample was taken. Forty-eight patients were recruited and had a complete follow-up (25 received ciprofloxacin and 23 placebo). Of the ciprofloxacin group, four patients (16%) had a UTI at the follow-up after catheter removal, and two were symptomatic. The UTI in two patients (including one of those symptomatic) was newly developed after catheter removal; the other two UTIs were a result of failure to resolve a catheter-associated UTI. All these UTIs in the ciprofloxacin group were resistant to ciprofloxacin. Of the placebo group, three patients (13%) had a UTI at the follow-up after removal, and one patient was symptomatic. The UTI, newly developed after catheter removal, was resistant to ciprofloxacin. The other two patients were asymptomatic; their UTIs were a result of failure to resolve a catheter-associated UTI, and one was resistant to ciprofloxacin. The risk of UTI (both symptomatic and asymptomatic) after removing a urethral catheter is real, even in absence of catheter-associated UTI before removal. UTIs occurring after removing a short-term urinary catheter had a high rate of resistance to ciprofloxacin. There was no detectable significant benefit in using prophylactic ciprofloxacin to reduce the UTI rate after catheter removal.

Urinary tract infection in the users of depot-medroxyprogesterone acetate.

The effects of progesterone on muscle tone, peristalsis of the ureter and also urinary vasculature may cause urinary tract infection (UTI) in women who use depot-medroxyprogesterone acetate (DMPA) for contraception. In a cohort study, 200 women who chose DMPA for contraception were compared with 200 women who used the withdrawal method for urinary infection and urological symptoms after 3 months of consumption. The rate of urinary infection and urological symptoms in the study group were higher than in the control group (p = 0.018, p < 0.0001, respectively). The most common microorganism that caused urinary infection was Escherichia coli. Among the 10 cases who suffered UTI in the case group, there were six women who had UTI in the previous pregnancy as well. We do not recommended administering depot-medroxyprogesterone acetate for contraception in women with a history of urinary tract infection in a previous pregnancy.

Totally tubeless percutaneous nephrolithotomy in selected patients.

Significant early postoperative discomfort after percutaneous procedures is usually secondary to nephrostomy tubes and externalized ureteral catheters. We describe our modification of the traditional percutaneous nephrolithotomy (PCNL) approach that we name "totally tubeless PCNL." Between June 2000 and May 2001, 60 consecutive PCNLs were performed at our centers. At the end of the surgery, we omitted the nephrostomy tube and removed the externalized catheter in selected patients: no solitary kidney, stone size <3 cm, and without any obstructions or arterial bleeding. A total of 30 patients underwent totally tubeless PCNL (group 1). We compared their results with those of a control group of 30 patients who underwent standard PCNL (group 2). The incidence of complications, analgesic requirements, length of hospitalization, and time to return to normal activities were compared in the two groups. In both groups, PCNL was performed successfully without any significant complications. A 90% stone-free rate was achieved in both groups, and in the remaining patients, small residual stones (<4 mm) were detected. No urinoma was demonstrated by postoperative ultrasound scanning in group 1. The average length of hospitalization was 1.5 days for group 1 and 3 days for group 2. The average analgesic requirements were 30 mg of pentazosin in group 1 and 90 mg in group 2. No transfusion was needed. There were three complications: 2 patients (6.6%) had urinary tract infection in group 1 and 1 (3.3%) in group 2. All were managed medically. Omitting the percutaneous nephrostomy tube and removing ureteral catheter at the end of surgery in selected patients were safe and accompanied by significantly reduced postoperative discomfort, length of hospitalization, and analgesic requirements. Further studies are needed to determine the role of this technique.

Predictive risk factors for chronic renal failure in primary high-grade vesico-ureteric reflux.

To evaluate and define the risk factors predictive of chronic renal failure (CRF) in children with severe bilateral primary vesico-ureteric reflux (VUR), observed within the first year of life and with a long follow-up. The study comprised 50 patients presenting with grade 3-5 bilateral VUR diagnosed in the first year of life; 12 were suspected prenatally and confirmed shortly after birth, before any urinary tract infection (UTI). The mean (range) follow-up was 6.3 (1-16) years. The variables considered within the first year of life were: gender, prenatal diagnosis with no UTI, number of febrile UTIs, serum creatinine and urea nitrogen levels, metabolic acidosis, proteinuria, 24-h urine output, hypertension, bilateral renal length on ultrasonography and renal scarring on renal scintigraphy. CRF was defined as a creatinine clearance of <80 mL/min/1.73 m(2) at the last follow-up. The results were assessed using univariate and multivariate analyses (backward-stepwise multiple regression) of the selected variables. CRF was detected at the last follow-up in 27 patients (54%), all boys, while renal function was normal in 23 (46%; seven girls). None of the 12 patients with prenatal diagnosis had UTI, but six had CRF. Febrile UTI was the presenting symptom in 38 (76%) patients and 17 (34%) of them had renal scarring. There was no significant difference between the prenatally detected VUR and febrile UTI group in the outcome as CRF. The univariate and multiple regression analysis showed that the first serum creatinine threshold of >6 mg/L before 1 year old was the most significant risk factor for CRF (P < 0.001; odds ratio 1.25). Children with primary bilateral high-grade VUR and a serum creatinine of > 6 mg/L in the first year of life have a significant risk of developing CRF in the long-term. Prenatal diagnosis and postnatal febrile UTI do not modify the outcome for renal function.

Urinary tract infections and genitourinary abnormalities in Cameroonian men.

To compare the prevalence of genitourinary abnormalities in men diagnosed with urinary tract infection (UTI) in a Cameroonian hospital and those without. Consecutive adult men aged 18-75 years, whose midstream urine samples were received for microscopy, culture and sensitivity at the microbiology laboratory of the Yaounde University Teaching Hospital, Cameroon, constituted the study population. Genitourinary abnormalities were diagnosed from history, physical examination, abdominal and transrectal ultrasonography, plain abdominal X-ray, and if indicated urethrocystoscopy and biopsy. Of the 206 patients who qualified, 179 completed the study and 63 (35.2%) were found to have UTI. A total of 41 (65.1%) patients with UTI (mean age 69.2 years) had at least one genitourinary abnormality, compared to 13 (11.2%) of those without UTI (mean age 61.9 years) (P < 0.001). The age-adjusted prevalence of genitourinary abnormalities was 59.4% in the UTI group and 12.1% in the non-UTI group (P < 0.001). The most frequent genitourinary abnormality in men with UTI was benign prostatic enlargement, followed by urethral stricture. The crude odds ratio (95% confidence intervals) for UTI associated with genitourinary abnormality was 14.77 (6.80-32.05), and the adjusted odds ratio 11.51 (7.08-29.46). Urological evaluation of Cameroonian men with UTI, using simple history taking, physical examination, ultrasound examination and plain abdominal X-ray, could have significant clinical benefits in this tropical African region.

UTI Risk Factors in Postmenopausal Women

Risk factors for urinary tract infection (UTI) have been well delineated in reproductive-aged women and older debilitated women but not in community-dwelling, generally healthy, older women. To examine risk factors for UTI in this important group, investigators identified 899 acute UTI cases and 911 controls (age range, 55-75) who were community-dwelling members of an HMO …

Immature ureteric jet doppler patterns and urinary tract infection and vesicoureteric reflux in children

The Doppler waveform of the ureteric jet is the result of modification of ureteric peristalsis by an active sphincteric mechanism of the vesicoureteric junction (VUJ). The monophasic pattern is associated with immaturity. This study set out to see the correlation between this immature pattern with urinary tract infection (UTI) and vesicoureteric reflux (VUR) in children. Ureteric jets of 241 healthy children and 98 children with UTI were studied. The monophasic pattern was found in 29% of healthy children overall, but varied greatly according to age. The monophasic pattern was virtually universal in the first 6 months of life, dropping to below 15% in late childhood. This immature pattern was more commonly seen in the UTI (73.5%) and VUR (90.5%) groups than in the healthy controls. The difference was statistically significant ( p = 0.0005 for both). The persistence of this immature pattern was highly associated with UTI and VUR.

Procalcitonin as a marker of acute pyelonephritis in infants and children.

In the absence of specific symptomatology in children, the early diagnosis of acute pyelonephritis is a challenge, particularly during infancy. In an attempt to differentiate acute pyelonephritis from lower urinary tract infection (UTI), we measured serum procalcitonin (PCT) levels and compared these with other commonly used inflammatory markers. We evaluated the ability of serum PCT levels to predict renal involvement, as assessed by dimercaptosuccinic acid (DMSA) scintigraphy. Serum C-reactive protein (CRP), leukocyte counts, and PCT levels were measured in 64 children admitted for suspected UTI. Renal parenchymal involvement was assessed by (99m)Tc-DMSA scintigraphy in the first 7 days after admission. In acute pyelonephritis, the median PCT level was significantly higher than in the lower UTI group (3.41, range 0.36-12.4 microg/l vs. 0.13, range 0.02-2.15 microg/l, P<0.0001). In these two groups, respectively, median CRP levels were 120 (range 62-249 mg/l) and 74.5 (range 14.5-235 mg/l, P=0.012) and leukocyte counts were 15,910/mm(3) (range 10,200-26,900) and 14,600/mm(3) (range 8,190-26,470, P=0.34). For the prediction of acute pyelonephritis, the sensitivity and specificity of PCT were 94.1% and 89.7%, respectively; CRP had a sensitivity of 100%, but a specificity of 18.5%. We conclude that serum PCT may be an accurate marker for early diagnosis of acute pyelonephritis.

Methenamine hippurate for preventing urinary tract infections.

Methenamine salts are often used for the prevention of urinary tract infection (UTI). To assess the effectiveness of methenamine hippurate in preventing UTI. Published and unpublished randomised controlled trials were identified from the Cochrane Controlled Trials Register, MEDLINE, EMBASE, CINAHL, Current Contents, reference lists of review articles and retrieved trials. The manufacturers' of methenamine salts were contacted for unpublished studies and contact was made with known investigators in the area. Randomised and quasi-randomised trials of methenamine hippurate used for the prevention of UTIs in all population groups were eligible for inclusion. A comparison with a control (no treatment) group was a prerequisite to selection. Two reviewers (BL and TB) performed independent assessment and data extraction using a standardised format. Discrepancies, methodological and interpretative issues were discussed with JS or JC. An exploration of heterogeneity as well as a detailed description of results grouped by population was conducted. Eleven studies met the inclusion criteria. All trials were included in a descriptive analysis. Seven trials were included in meta-analyses. Four trials (199 patients) studied symptomatic bacteriuria and six trials (341 patients) studied bacteriuria as an outcome measure. Overall, trial quality was poor. The direction of six of the pooled trials was towards a favourable treatment effect from methenamine hippurate. Interpretation of the pooled estimates was not done in view of underlying heterogeneity. The study by Pettersson 1989 explained some, but not all, of the underlying heterogeneity. This study differed from all others by including patients with known upper renal tract abnormalities. Adverse reactions were mentioned by 10 studies. The rate of adverse events was low. There is not enough evidence to conclusively support the use of methenamine hippurate for urinary prophylaxis. An exploration of heterogeneity raises the (hypothesis generating) possibility that methenamine hippurate may have some efficacy in patients without but not in patients with known upper renal tract abnormality (with asymptomatic bacteriuria as the outcome measure). Due to the small sample size and methodological problems within the studies involved, interpretation of these data should be done cautiously. The rate of adverse events reported by the trials was low, which suggests that current usage is unlikely to be causing significant harm.

The significance of interleukin 8 in urine

AIMSTo assess the implications of detection of interleukin 8 (IL-8) in urine.METHODSIL-8 was measured by immunoassay in all 305 urine samples from children aged 0–18.4 years received by our microbiology...

Maternal urinary tract infection alters water maze performance in the offspring

The effects of maternal urinary tract infection (UTI) or endotoxin exposure on fetal outcome in rats were investigated. Prior to conception, dams of the UTI group were water-deprived and anesthetized. The urinary tract was then catheterized and injected with 0.2 of 1×10 9 Escherichia coli. The endotoxin group was injected with 0.03 mg/kg lipopolysaccharide on the fourth day of gestation and then every third day thereafter. The control groups were treated in the same manner, with the exception that the infection control was not catheterized or injected with E. coli, and the endotoxin control was not exposed to lipopolysaccharide. A nontreated control group was weighed daily. Beginning on postnatal day (PD) 19, offspring were tested daily in a water maze spatial navigation task. The retention latencies (Sessions 7–10) revealed deficits in the infection and endotoxin groups. In the rat model, these findings suggest that exposure during gestation to a maternal immune challenge may result in adverse fetal outcome.

Work-up of urinary tract infection in infants and children.

Urinary tract infection (UTI) in infants and children demands rapid differentiation between upper UTI (pyelonephritis) and lower UTI (cystitis) for prompt treatment to be initiated so that renal damage is minimized. This pictorial review presents a wide gamut of structural and functional abnormalities of the urinary tract that may predispose infants and children to UTI, including vesicoureteral reflux, upper urinary tract obstruction (ureteropelvic junction obstruction), lower urinary tract obstruction (primary megaureter, ureterovesical junction obstruction, posterior urethral valve, ectopic ureterocele with or without associated duplex collecting system), neurogenic problems (dysfunctional voiding), calculi, and parenchymal scars. Sonography (ultrasound [US]) is the imaging modality of choice for assessment of renal size, growth (serial sonograms), texture, and blood flow. Other modalities used to work-up UTI in the pediatric patient include fluoroscopic voiding cystourethrogram, nuclear voiding cystourethrogram, and nuclear renal scintigraphy (NRS). Excretory urography is no longer recommended in the routine evaluation of childhood UTI because information regarding anatomy and function (qualitative and quantitative) can be better assessed with US and NRS, respectively. Computed tomography and magnetic resonance imaging are primarily reserved for complex cases in which a definitive diagnosis cannot be made with routine imaging. Algorithms for work-up of UTI in various pediatric age groups are presented.

Could the incidence of postoperative urinary tract infection be reduced by reversing the sequence of vaginal cleansing and urethral catheterization?

Postoperative urinary tract infection (UTI) is a common hospital infection after gynaecological operations. A prospective randomized study was performed to examine whether the incidence of UTI could be reduced by reversing the sequence of vaginal cleansing and urethral catheterization. Subjects were randomly allocated to: (1) urethral catheterization before vaginal cleansing; and (2) urethral catheterization after vaginal cleansing. Urine cultures were performed immediately after the procedures as the baseline, on the day of catheter removal, and two days after catheter removal. Patients were examined daily after the operation for any urinary symptoms and fever. The incidences of preoperative asymptomatic bacteriuria were similar in both groups, seven of 84 in group 1 vs. eight of 83 in group 2. Among those with negative urine culture before the operation, 77 in group 1 and 75 in group 2, there was no significant difference in postoperative bacteriuria at catheter removal (23 vs. 22) and two days later (35 vs. 42). No significant difference was noted in the incidence of UTI (5 vs. 10, P 0.25), with a trend towards less UTI in group 1. Voiding discomfort was more common, and fever less common in group 1. There were significant associations between urine culture results at three different occasions. Bacteriuria at catheter removal is associated with a 7.2 times risk of bacteriuria two days later, 2.4 times risk of urinary symptoms and 3.2 times risk of UTI. Routine surveillance at catheter removal is not cost-effective.We conclude that postoperative bacteriuria and UTI are common. Reversing the sequence of the procedures cannot reduce the incidence. There is no evidence to change the status quo.

Association of Weight Status With Urinary Tract Infections in Nursing Home Residents

Poor weight status in nursing home residents is associated with increased morbidity, mortality and costs. Aggressive nutrition therapy may remediate the abnormality if inadequate nutrition is the primary cause, but may be futile if progressive disease is the primary cause. A pilot study examined factors associated with weight change over three months in newly admitted undernourished patients (n=43). Absence of urinary tract infection (UTI) was significantly (p<.05) associated with weight gain in both males (r=.45) and females (r=.63). To further explore this relationship the weight status of 78 nursing home residents (63 females, and 16 males) who had contracted at least 1 UTI was monitored over a six-month period using medical record data. Females with 3 or more UTIs on average lost weight, whereas those with only 1 UTI did not. Mean percent weight change ±std.dev. in females in the 3+UTI group was −3.5±6.8%, and was significantly different (t-test, p<.03) than that of the 1 UTI group which was +0.4±3.8%. No significant associations with frequency of UTI were found with percent change of weight in men or with final body mass index in either gender.

Low-dosage cefepime as treatment for serious bacterial infections

Since infection develops in significant numbers of hospitalized patients, the problem of resistance to third-generation cephalosporins is of increasing concern. We evaluated the efficacy of cefepime 1 g bd as treatment for acute, moderately severe bacterial infection in 239 hospitalized patients (mean age 60 years). Of these patients, 204 were evaluated clinically for urinary tract infection (UTI) (n = 90), lower respiratory tract infection (LRTI) (n = 70), skin and soft tissue infection (S/STI) (n = 12) and bacteraemia which was associated with either UTI or LRTI (n = 32) but not included in the previously mentioned UTI and LRTI groups. Amongst the pathogens isolated (36 Gram-positive, 150 Gram-negative), the most predominant species were Escherichia coli in UTI and bacteraemia (n = 81), Streptococcus pneumoniae in LRTI and bacteraemia (n = 23), Haemophilus influenzae in LRTI (n = 16), Pseudomonas aeruginosa (n = 4) and Enterobacter cloacae (n = 2) in S/STI. The mean duration of treatment was 8.5 days and was the same for the 204 clinically evaluable patients. Overall, the clinical cure rate for cefepime was 94% (191/204). Pathogen eradication was achieved in 93% (185/199) of infections. Of the patients with associated bacteraemia, the clinical cure rate was 97% (31/32) and 94% (16/17) of the pathogens were eradicated. Cefepime therapy was well-tolerated. Treatment was discontinued in eight patients (3%) because of local intolerance and in five patients (2%) because of drug-related adverse events (rash, headache and pruritus). Cefepime 1 g bd is as safe and effective as other parenteral cephalosporins for the treatment of acute bacterial UTI, LRTI and S/STI, including those cases with associated bacteraemia. The bd dosing schedule and reported lack of cross-resistance with other cephalosporins against some species of aerobic Gram-negative bacilli make cefepime an attractive treatment option in hospitalized patients.

Quantitation of urinary Tamm-Horsfall protein in children with urinary tract infection.

It has been suggested that urinary Tamm-Horsfall protein (THP) prevents colonization of the urinary tract by binding uropathogens. We tested the hypothesis that low urinary THP levels may predispose to urinary tract infection (UTI) by measuring THP levels in children. We studied a cohort of 35 girls with uncomplicated recurrent UTI (group 1) that was compared with 27 patients with myelomeningoceles undergoing clean intermittent catheterization (group 2) and 16 female controls (group 3). We measured urinary THP in both aggregated (aTHP) and disaggregated form (dTHP), leukocyte esterase activity, urine chemistries and culture. No significant differences in dTHP or aTHP levels were seen between groups 1 and 3, but group-1 patients had higher dTHP levels than group-2 patients (p < 0.008). History of reflux or the presence of bacteriuria or pyuria at the time of urine collection did not affect dTHP levels; in contrast, pyuria or bacteriuria at the time of sampling was associated with markedly lower aTHP levels when compared with sterile samples (p < 0.0001). For all groups, measured quantities of dTHP did not correlate with aTHP levels. We conclude that excretion of dTHP in children with history of recurrent UTI is not reduced. In contrast, concentrations of aTHP are profoundly depressed in children during times of UTI, suggesting a role for THP in the pathogenesis of UTI. Assaying THP in its aggregated form may prove valuable when studying its physiologic function and merits further investigation.