Bacteriuria and safety of female urodynamic studies

Introduction and hypothesis

Our aim was to study the incidence of bacteriuria after urodynamic studies (UDS) and prevalence of asymptomatic bacteriuria before UDS.

Methods

In this prospective study between March and September 2011, 140 women undergoing UDS were subjected to urine culture before the investigation. Urine was collected aseptically with a sterile catheter transurethrally. Multichannel UDS were performed 3–5 days after urine collection. Prophylactic antibiotics were not administered to these women. A second urine sample was collected within 5–7 days after UDS. Significant bacteriuria was defined as 10² colony-forming units (cfu)/ml or more of a single organism cultured.

Results

Thirty (21.4 %) women had asymptomatic bacteriuria before UDS and were excluded from the main study group. Among the 110 women in the study group, 4 (3.6 %) acquired infection after UDS. Three grew organisms found in the vagina (group B Streptococcus and yeast-like organism) and one grew Proteus mirabilis. Age 60 years and above is a significant risk factor. In contrast to the study group, among 30 women who had infection before UDS, Escherichia coli was the commonest pathogen in 19 (63.3 %) and 30 % had diabetes. Eleven (36.7 %) had persistent infection after UDS and the rest resolved spontaneously. In addition, no other related complication was observed on the UDS.

Conclusions

This study shows that risk of post UDS bacteriuria is low in women and screening for vaginal infections may be necessary before UDS. Women over 60 years old are significantly at risk of infection. Bacteriuria is nevertheless mostly asymptomatic and transient in nature.     

Prevalence of asymptomatic bacteriuria in knee arthroplasty patients and subsequent risk of prosthesis infection

Introduction

The risk of knee arthroplasty infection and appropriateness of antibiotic treatment are not clearly established in patients with preoperative asymptomatic bacteriuria. It has been the purpose to analyze the prevalence of preoperative asymptomatic bacteriuria in knee arthroplasty patients, as well as the incidence of prosthetic joint infection in those with asymptomatic bacteriuria treated and not with specific antibiotics.

Patients and methods

This prospective study included 215 consecutive knee arthroplasty patients (73 ± 6 years, 168 females) with neither urinary symptoms nor perioperative urethral catheterization. A “clean-catch” urinalysis was obtained from all patients before surgery and an urine culture if urinalysis was abnormal. Asymptomatic bacteriuria was diagnosed if >100,000 colony-forming units/ml were cultured. Patients were treated (Group A) or not (Group B) with additional specific antibiotics for urine bacteria according to surgeon criteria. Minimum follow-up reached 48 months. No patient was lost to follow-up.

Results

Asymptomatic bacteriuria was diagnosed in 11/215 patients (5.1 %) (11/11 females), and four of these 11 were treated with specific antibiotics (Group A). Only one patient in Group A suffered a prosthesis infection along the first 3 months (1/125, 0.5 %), but bacteria cultured from the wound were absolutely different to those in urine culture. No patient in Group B suffered a prosthesis infection.

Conclusions

Asymptomatic bacteriuria presents a low prevalence. We have not found any case of arthroplasty infection from urinary focus in patients with asymptomatic bacteriuria whether they received or not specific antibiotics.

     

Morbidity of Urodynamic Investigation in Healthy Women

The morbidity of diagnostic catheterization in healthy women has never been described. In order to further elucidate the natural history of postcystometry bacteriuria we studied a group of healthy women without lower urinary tract symptoms. Thirty female volunteers aged 39–72 years underwent urine sampling prior to and at day 3 after invasive urodynamic evaluation. One case of asymptomatic bacteriuria was detected among pretest samples. On post-test sampling 10 of 29 cultures were positive. With a cut-off level of >10⁵ CFU/ml only 2 cases could be classified as significant bacteriuria. Only 1 was symptomatic. The remaining 29 women had no symptoms following the examination. Thus the incidence of lower urinary tract infection was 3.3% following repeated diagnostic catheterization. We concluded that although bacteriuria is common after diagnostic catheterization, it is essentially asymptomatic.     

Intravesical Bacille Calmette-Guérin Eradicates Bacteriuria in Antibiotic-naïve Bladder Cancer Patients

Background

Intravesical bacille Calmette-Guérin (BCG) therapy is safe and effective in bladder cancer patients who have asymptomatic bacteriuria. BCG induces robust immune responses in the bladder that are responsible for its antitumor effect. We hypothesize that BCG-induced inflammation may eradicate bacterial infection.

Objective

To investigate whether intravesical BCG therapy alone can eradicate bacterial infection in antibiotic-naïve bladder tumor patients who have asymptomatic bacteriuria.

Design, setting, and participants

A single-institution prospective cohort study of bacteriuric adults with non–muscle-invasive bladder tumors who underwent outpatient BCG therapy or surveillance cystoscopy.

Intervention

Ninety high-risk patients received induction intravesical BCG without maintenance BCG, and 95 low-risk patients who had not received BCG underwent outpatient surveillance cystoscopy. Each patient had significant bacteriuria on urine culture, and none received routine antibiotics before, during, or after procedures.

Outcome measurements and statistical analysis

Urine cultures were repeated after 3, 6, and 12 mo. All patients had follow-up cystoscopy every 3 mo and were followed for a minimum of 1 yr. The end point was number of BCG-treated and cystoscopy patients who became bacteria free at 3, 6, and 12 mo.

Results and limitations

Two BCG-treated patients (2.2%) and six patients after cystoscopy (6%) developed febrile urinary tract infection (p = 0.21). All resolved with antibiotics. No patient was admitted for sepsis. Of 88 infected patients who received BCG without routine antibiotics, 58 (66%) were continuously bacteria free at 1 yr compared with 16 of 89 cystoscopy patients (18%; p = 0.001). The prospective observational study design prohibits causal inference of antibacterial effects attributed to BCG over cystoscopy.

Conclusions

Intravesical BCG therapy is associated with clearance of uropathogens in bladder cancer patients, possibly due to augmented innate host immunity.     

Urinary tract infection after urodynamic studies in women: incidence and natural history

OBJECTIVE: To study the incidence, natural history and symptomatic effects of bacteriuria after urodynamic studies in women. PATIENTS AND METHODS: In a prospective study in the urogynaecology clinic of a large District General Hospital, 214 women (mean age 52.3 years, range 23-81) underwent urodynamic studies. Bacteriuria was detected by semiquantitative culture at 2 and 7 days after the test. Women completed a 7-day diary of symptoms and events. RESULTS: The incidence of bacteriuria after urodynamic studies was 7.9%. Bacteriuria was transient in four of 17 women but persisted in nine and developed late in four; only one of 17 infections gave rise to symptoms. Irritative bladder symptoms after the test occurred in 34% of women, but only three went to their doctors because of concern about a possible urinary tract infection. Advancing age was the only variable associated with bacteriuria after urodynamic studies (P= 0.05). Menopausal status, past history of urinary tract infection, number of urethral instrumentations required, order number in a session, peak urinary flow rate and urodynamic diagnosis were not associated variables. CONCLUSIONS: In a large series of women presenting to a urogynaecology clinic, urodynamic investigations were associated with a high incidence of transient irritative symptoms but a low incidence of bacteriuria (8%). Infection was asymptomatic in most patients, but its natural history was unpredictable. Transient, persistent and late cases of bacteriuria all occurred. In this population, urodynamic studies are associated with a low level of morbidity.     

Utilization of extended donor criteria liver allograft: Is the elevated risk of failure independent of the model for end-stage liver disease score of the recipient?

BACKGROUND: The role of asymptomatic bacteriuria in kidney transplant recipients is unknown. There is no clear evidence of its effect on transplanted kidney. METHODS: We studied urine cytokines profile among kidney transplant recipients with bacteriuria found in screening examination. Urine cultures were collected in 269 patients with stable graft function and serum creatinine level <2 mg/dl, during their routine visits. Interleukin (IL)-6 and IL-8 levels were measured in urine samples from patients with asymptomatic bacteriuria, symptomatic urinary tract infection and patients without bacteriuria (control group). Changes in serum creatinine level in patients with asymptomatic bacteriuria and in the control group were observed during 12 months follow up. RESULTS: Urinary tract infection (UTI) was diagnosed in five patients and asymptomatic bacteriuria in 22 patients. Urine IL-6 level was significantly higher in symptomatic UTI group (median 15.71 pg/mg) but there were no differences between group of patients with asymptomatic bacteriuria (3.92 pg/mg) and control group (2.54 pg/mg). Urine IL-8 level was higher in symptomatic UTI group (median 146.8 pg/mg) and was also significantly higher in asymptomatic bacteriuria group (33.49 pg/mg) in comparison to control group (2.97 pg/mg; P=0.0002). During 1-year follow up, incidence of UTI was higher in the asymptomatic bacteriuria group than in the control group but graft function was not different in both groups. CONCLUSIONS: Elevated urine IL-8 level in kidney transplant patients with asymptomatic bacteriuria may reflect impaired immune response to bacterial infection and occult inflammatory process in urinary tract.     

The Prevalence of Urinary Tract Infections in Patients with Gestational Diabetes Mellitus

Microbiologic evidence of urinary tract infection was studied in 447 pregnant women with (n= 149) or without (control group, n= 298) gestational diabetes mellitus after mid-pregnancy. Laboratory investigations included chemical analysis, microscopic examination and culture of a clean midstream voided urine specimen. Nineteen women (4.2%) had asymptomatic bacteriuria (7 study, 12 contorl, P = 0.7). Of these, 7 (38%) developed symptomatic infection despite treatment with antibiotics (2 study, 5 control, P = 0.7) and 6 (31%) had recurrent bacteriuria later in pregnancy (3 study, 3 control, P = 0.3). Twelve more women (2.6%) had symptomatic infection (5 study, 7 control, P = 0.5), 7 had acute cystitis (3 study, 4 control, P = 0.5) and 5 had acute pyelonephritis (2 study, 3 control, P = 0.7). Escherichia coli was the commonest pathogen, accounting for 22 (71%) infection episodes. Gestational diabetes mellitus was not associated with increased risk of urinary tract infections nor of maternal and perinatal morbidity as a result of infection.     

Urinary tract infections and bacteriuria after gynecological surgery: Experience with 24-hour foley catheterization

The risks of urinary tract infection (UTI) and asymptomatic bacteriuria (AB) associated with short-term catheterization have not yet been established. A prospective observational study was carried out to determine the rates of UTI and AB when transurethral Foley catheterization was used for 24 hours. The study population was 193 women undergoing routine gynecologic surgery. All had negative preoperative urine cultures, and prohylactic antibiotics were not used.Postoperative UTI developed in 16 patients (8.3%), i.e. in only 14 of 86 with a positive culture on day 1 after surgery, and in 2 of 107 with a negative culture on day 1. These 16 women received antibiotics; 79 (40.9%) who had transient AB were not treated. There were no cases of upper UTI. Among 31 women discharged with AB, none developed UTI.Although 49.2% of patients in this study had postoperative bacteriuria as measured by midstream culture, only 8.3% of patients actually developed a symptomatic infection requiring treatment. As only a minority (11.3%) of patients with postoperative AB actually developed UTI, it appears that to treat all cases of bacteriuria >100 000 cfu/ml is unnecessary.     

The Prevention and Management of Urinary Tract Infections Among People With Spinal Cord Injuries

ABSTRACT

The Urinary Tract Infection Consensus Conference brought together researchers, clinicians, and consumers to arrive at consensus on the best practices for preventing and treating urinary tract infections in people with spinal cord injuries; the risk factors and diagnostic studies that should be done; indications for antibiotic use; appropriate follow-up management; and needed future research. Urinary tract infection (UTI) was defined as bacteriuria (102 bacteria/ml of urine) with tissue invasion and resultant tissue response with signs and/or symptoms. Asymptomatic bacteriuria represents colonization of the urinary tract without symptoms or signs.

Risk factors include: over-distention of bladder, vesicoureteral reflux, high pressure voiding, large post-void residuals, presence of stones in urinary tract, and outlet obstruction. Possible physiologic/structural, behavioral, and demographic risk factors were identified also. Indwelling catheterization, including suprapubic, and urinary diversion are the drainage methods most likely to lead to persistent bacteriuria. Infection risk is reduced with intermittent catheterization, but more severely disabled people who require catheterization by others are at greater risk for UTIs. Clean self-intermittent catheterization does not pose a greater risk of infection than sterile self-intermittent catheterization and is much more economic. However, care must be given to proper cleansing of reusable catheters.

Quantitative urine-culture criteria for the diagnosis of bacteriuria include: catheter specimens from individuals on intermittent catheterization ≥10² cfu/ml; clean-void specimens from catheter-free males using condom collection devices ≥10⁴ cfu/ml; and specimens from indwelling catheters of any detectable concentration. Dip stick screening tests may offer promise as an early warning system of UTI since they can be self-administered.

Symptomatic UTI should be treated with antibiotics for 7 to 14 days. Longer courses have not been beneficial. In patients with symptomatic UTIs, it is not necessary to wait for the results of cultures before starting treatment. Asymptomatic bacteriuria need not be treated with antibiotics. There is little evidence presently to support the use of antibiotics to prevent infections.

Following a recent episode of febrile UTI, possible contributing prior events should be reviewed. The upper tracts should be evaluated (imaging studies) to identify possible abnormalities. A common concern among people with spinal cord injuries is that physicians will alter bladder management programs without regard to lifestyle needs. Social/vocational flexibility may be more important to them than a state-of-the-art bladder management program.

Future research should focus on obtaining more representative samples and investigate psycho-social-vocational implications as well as additional clinical-medical factors.     

Complications and treatment of urinary tract infections during pregnancy

Bacteriuria during pregnancy may result in serious complications, including development of acute pyelonephritis in the third trimester and premature labor. Because uninfected women commonly experience symptoms associated with urinary tract infections and many bacteriuric women are asymptomatic, all pregnant women should be screened by quantitative urine cultures. The goal of antimicrobial therapy is complete elimination of bacteria from the urinary tract. Major indications for complete urologic evaluation are failure of a patient with signs of acute upper-tract infection to improve on appropriate treatment and bacterial persistence after initial sterilization of the urine. Either problem may require surgical intervention.     

Asymptomatic bacteriuria in men with orthotopic ileal neobladders: possible relationship to nocturnal enuresis

OBJECTIVE: To assess prospectively the incidence with time of asymptomatic bacteriuria in patients with orthotopic ileal neobladders, and the possible effect on neobladder function. PATIENTS AND METHODS: In all, 47 patients (mean age 52.7 years, sd 8.7, range 31-68) with uncomplicated orthotopic ileal neobladders were prospectively evaluated. With no antibiotic manipulation, consecutive urine cultures were assessed monthly. Continence was assessed by direct information from the patients at each follow-up visit. RESULTS: Overall, 797 samples were cultured from the 47 patients (mean 17.6, sd 7.1). There was a steady decrease in the incidence of positive cultures, from 74.5%, to 35.6% and 6.7% at 1, 6 and 18 months, respectively. While there was persistently sterile urine in only eight patients (17%), 32 had occasional and seven had persistent bacteriuria. Escherichia coli was the commonest organism (76.6%) followed by Klebsiella pneumonia (15.7%); 54% of E. coli and 38% of K. pneumonia infections were sensitive to nitrofurantoin. Diurnal continence was achieved in 98% of the patients at 6 months after surgery. There was a gradual decrease in the frequency of nocturnal enuresis (NE) with time, from 87%, to 42%, 28% and 27% at 1, 6, 12 and 18 months, respectively. There was a significant correlation between the presence of bacteriuria and NE during the first 6 months, but it was not sustained after that. The age of the patients was also related significantly to the incidence of NE; at 6 months, only one of 18 men aged < or = 50 years had NE, while 19 of 29 aged > 50 years had (P < 0.001). At 1 year all patients aged < or = 50 years were nocturnally continent, while half of those aged > 50 years had NE (P = 0.001). CONCLUSIONS: Ileal neobladders are associated with a high incidence of asymptomatic bacteriuria during the first year after surgery. There was spontaneous clearance of bacteriuria with time, with no antimicrobial manipulation. Soon after surgery there was a significant association between bacteriuria and NE. The effect of antimicrobials on patients with NE should be evaluated.     

Bacteriuria in patients with an orthotopic ileal neobladder: urinary tract infection or asymptomatic bacteriuria?

OBJECTIVE

To investigate the prevalence of asymptomatic bacteriuria (ABU) and urinary tract infection (UTI), and the local and systemic inflammatory response, in patients with ileal neobladder.

PATIENTS AND METHODS

The study included 40 patients who had a radical cystectomy and ileal neobladder. Two urine samples, one for chemical and physical analysis, and cytofluorimetry, and one for urine culture, were collected every 3 months for 9 months after surgery.

RESULTS

Of 119 urine cultures, 69 (57%) were positive for bacteria. Only nine of the 40 patients had no bacteriuria on urine culture. Escherichia coli strains were cultured from eight of 10 patients with persistently positive urine. The incidence of bacteriuria was different according to gender. There was a high concentration of leukocytes (0–6 µL) in 118 of 119 samples. The mean concentration of leukocytes in sterile urine culture was 1181/µL, while in patients with ABU the mean was 491 (P < 0.05).

CONCLUSION

A positive urine culture is a very common finding in patients with an orthotopic bladder. The most interesting results was the absence of elevated inflammatory indices and/or symptoms, even in those patients with high levels of bacteriuria. Probably this is due to the completely different inflammatory response of ileal mucosa against bacteria than has bladder mucosa. Indeed, the leukocyte concentration detected in urinary sediment was inversely association with bacterial growth in urine cultures. These findings suggest a redefinition of ABU and UTI in patients with an orthotopic neobladder.     

Studies of introital colonization in women with recurrent urinary infections. VIII. The role of bacterial interference.

The non-pathogenic aerobic bacteria in 97 quantitative introital cultures from 11 women with documented recurrent bacteriuria were compared statistically to those in 100 quantitative introital cultures from 10 control women with no history of bacteriuria. The colonization incidence of the non-pathogenic organisms was not statistically different for the 2 groups, except for gamma hemolytic Streptococcus (p equals 0.002). No strongly significant correlations were demonstrated between the colonization incidence of Enterobacteriaceae or enterococci and the colonization incidence of the common non-pathogenic organisms, when analyzed for the bacteriuric and control groups or when analyzed for the individual cultures of each subject. A quantitative analysis of the 197 individual cultures failed to establish correlations between the presence of the common non-pathogenic organisms and Enterobacteriaceae or enterococci. The susceptibility of the vaginal introitus to colonization by urinary pathogens cannot be explained by interrelationships between these pathogens and the normal aerobic vaginal flora.     

Is colony count necessary?

Evidence presented herein suggests that: (1) If the Gram stain of the spun urinary sediment is negative, there is no need to do a culture, sensitivity test, and colony count since significant bacteriuria and urinary infection are not present. There are very few false negative results. (2) Since there are many false positive Gram stains, the test is not specific. A positive Gram stain of the spun urinary sediment does not mean that bacteriuria is present. (3) The test is very sensitive in that practically all bacteriuric subjects had a positive Gram stain. (4) Because the Gram stain of the spun urinary sediment is so sensitive, a positive spun urinary sediment and culture should be treated regardless of the colony count.     

Use of antibiotics in the conjunction with extracorporeal lithotripsy

The first 400 patients treated on an inpatient basis at our center underwent bacteriological follow-up after extracorporeal lithotripsy (ECL) for ureteric or renal stones. 278 patients did not have any urinary tract infection on the urine culture before ECL. They did not receive any antibiotic prophylaxis and 4.8% of the patients developed infectious problems, with significant bacteriuria in only 1.5% of the cases. 89 patients had urinary tract infection on the preoperative cultures. 21.3% developed either fever or significant bacteriuria and this virtually always occurred in patients who were treated for less than 4 days before ECL, with septicemia in 4.5% of the cases. 33 patients with sterile urine received flush antibiotic prophylaxis and none of them developed postoperative infection. Two of these patients had infection at the time of the flush: one of them, who, by error, did not receive antibiotic treatment prior to ECL, developed bacteremia after the procedure. The rational use of antibiotics in conjunction with ECL should ensure effective prevention of urinary tract infections without requiring the excessive use of antibiotics.     

High incidence of bacteriuria in early post-kidney transplantation; results from a randomized controlled study

Since the incidence of bacteriuria in kidney transplant recipients varyes according to the study, we examined it among our cases. Our post hoc analysis of data from a single-center, parallel, randomized, controlled, open label study included 90 patients who underwent kidney transplantation at our hospital from April 2010 to January 2011. Patients were randomized to early ureteric stent removal at 8 days versus routine ureteric stent removal at 15 days after kidney transplantation. We identified the incidence of and causative organism for bacteriuria in the early posttransplant period.Seventy-Four patients (58% living donors) participated in this study. The overall incidence of bacteriuria was 56.7% during the first month after kidney transplantation. In patients who had bacteriuria, 48% showed symptomatic urinary tract infection, 40% asymptomatic bacteriuria and 12% urosepsis. The most common organism was Escherichia coli (40%) follow by Klebsiella pneumoniae (19%). The incidence of an ESBL producing organism was 34%. The incidence of bacteriuria was high during the early post-kidney transplant period, requiring increased awareness and surveillance.     

Urinary urgency and frequency, and chronic urethral and/or pelvic pain in females. Can doxycycline help?

PURPOSE: Persistent urinary urgency and frequency, and chronic urethral and/or pelvic pain in women are often a diagnostic and therapeutic challenge. This can be frustrating for patients and physicians. The search for an infectious agent often proves futile and after multiple ineffective treatment regimens patients may be classified as having interstitial cystitis or referred to a psychiatrist as the last option. We evaluated whether treatment with doxycycline of the patient and her sexual partner would be beneficial. MATERIALS AND METHODS: Women presenting with a history of urinary urgency and frequency, and chronic urethral and/or pelvic pain often associated with dyspareunia and/or a history of recurrent urinary tract infection were evaluated. Initial examinations included urethral and cervical/vaginal swabs, serum analysis, urine examination and culture, and bladder barbitage. A total of 103 women with a median age of 46 years (range 21 to 84) and with a median symptoms history of 60 months (range 3 to 480) were included. All patients had trigonal leukoplakia at cystoscopy, in 15% an infectious organism was identified and 30% had leukocyturia. All were treated with doxycyclines, and a vaginal antimicrobic and/or antimycotic agent following the same regimen, including treatment of the sexual partner. RESULTS: After treatment with doxycycline 71% of the women were symptom-free or had a subjective decrease in symptoms. CONCLUSIONS: Treatment with doxycycline is effective in more than two-thirds of patients complaining of persistent frequency and urgency, chronic urethral and/or pelvic pain, and dyspareunia as well as a history of recurrent urinary tract infections. In women with negative urinary cultures but a history of urgency/frequency probative treatment with doxycycline is justified and endoscopic findings may support the hypothesis of chronic infection. This should be done especially before contemplating psychiatric treatment or diagnosing the patient with interstitial cystitis. We attribute this high success rate to simultaneous treatment of the sexual partner, who may be an asymptomatic carrier, although this remains to be proved.     

Urodynamic studies in women with stress urinary incontinence: Significant bacteriuria and risk factors

AIM: A prospective study was performed to determine the incidence of significant bacteriuria and to identify the risk factors for bacteriuria after urodynamic studies (UDSs) in women with urodynamic stress urinary incontinence (SUI). METHODS: A total of 225 women with urodynamic SUI were evaluated. All women were negative on double-screened urine cultures, in clean-catch midstream urine (MSU) specimens, before UDS. Another urine specimen was obtained for urinalysis and culture at 3-7 days after UDS. Urinary culture with 10(5) CFU/ml or more was regarded as significant bacteriuria. To identify the risk factors for significant bacteriuria, the clinical characteristics of all patients including age, BMI, parity, medical and operation history, degree of pelvic organ prolapse, results of urinalysis, and UDS were evaluated. RESULTS: The prevalence of significant bacteriuria was 6.2%. The most common identified microorganism was Escherichia coli (57.1%). Univariate analysis demonstrated that a history of recurrent urinary tract infection (UTI; P = 0.002) and urological surgery or procedure (P = 0.02) were significant predictors of significant bacteriuria. On multiple logistic regression analysis the past history of recurrent UTI was the only significant independent risk factor (OR = 28.5, 95% CI = 4.309-188.488, P = 0.009). CONCLUSIONS: This study suggests that for most women with SUI it may be unnecessary to use preventive prophylactic antibiotics in UDS. However, our results suggest that in patients with a previous history of recurrent UTI or urologic surgery the risk for significant bacteriuria is increased and use of prophylactic antibiotics should be considered.     

Urinary Tract Infections in the First Year Post–Kidney Transplantation: Potential Benefits of Treating Asymptomatic Bacteriuria

Background

Urinary tract infections (UTIs) are the commonest infectious complication in kidney transplant recipients (KTRs). No recommendations exist regarding treatment of asymptomatic bacteriuria. We aimed to identify potential risk factors and microbiological profile for UTIs, the role of treatment of asymptomatic bacteriuria, and effects on graft outcomes of bacteriuria within the first year post-transplantation.