Detection of urinary tract infection (UTI) in long-term care setting: Is the multireagent strip an adequate diagnostic tool?

Urinary tract infection (UTI) is one of the most commonly diagnosed and treated infection in elderly residents of long-term care (LTC) setting, and most of them are asymptomatic. Early diagnosis and treatment especially in this group of patients is very important because even a brief delay contributes to mortality as well as to reduce functional and cognitive decline. The purpose of the present study was to determine the validity of multireagent strips (Multistix 10 SG, Bayer, UK) compared with standard urinalysis for the early detection of UTI in LTC elderly patients. Urine specimens were examined for the presence of leukocyte esterase (LE) activity as an indicator of pyuria, nitrite production as an indicator of bacteriuria, erythrocytes (RBC), and protein. The sensitivity, specificity, predictive value, kappa agreement, and likelihood ration were determined for each of the four dipstick parameters measurement separately, and in four combinations were calculated against the urine culture for the diagnosis of UTI and asymptomatic bacteriuria. Ninety-six patients aged 65 years and older with symptomatic UTI were compared with similar number, age, sex and comorbidity status matched patients with asymptomatic bacteriuria. In both groups, urinary culture results were compared with the results of multireagent strips. The multireagent strips results were evaluated for the presence of LE activity as an indicator of pyuria, nitrite production as an indicator of bacteriuria, RBC, and protein. All positive sticks results were evaluated as single parameter and in combination of them. Positive urine cultures were found in 71% (68/96) of the patients with symptomatic and in 60% (58/96; p>0.05) of patients with asymptomatic UTI. In patients with UTI, using multireagent strips kappa agreement for LE was 0.53, for nitrite was 0.14, and in combination of them was 0.31. Similar results were reported in patients with asymptomatic bacteriuria, 0.35, 0.23, and 0.35m. The detection of RBC and protein, as single parameter or in combination with other parameters, decreases accuracy of the tests. Positive dipstick tests for LE and/or nitrite are not specific indicators of UTI, and are not suitable for screening of LTC inpatients for UTI because of high false-negative rates of the LE and nitrite.     

Clinical Features to Identify Urinary Tract Infection in Nursing Home Residents: A Cohort Study

OBJECTIVES: To identify clinical features associated with bacteriuria plus pyuria in noncatheterized nursing home residents with clinically suspected urinary tract infection (UTI).
DESIGN: Prospective, observational cohort study from 2005 to 2007.
SETTING: Five New Haven, Connecticut area nursing homes.
PARTICIPANTS: Five hundred fifty-one nursing home residents each followed for 1 year for the development of clinically suspected UTI.
MEASUREMENTS: The combined outcome of bacteriuria (>100,000 colony forming units from urine culture) plus pyuria (>10 white blood cells from urinalysis).
RESULTS: After 178,914 person-days of follow-up, 228 participants had 399 episodes of clinically suspected UTI with a urinalysis and urine culture performed; 147 episodes (36.8%) had bacteriuria plus pyuria. The clinical features associated with bacteriuria plus pyuria were dysuria (relative risk (RR)=1.58, 95% confidence interval (CI)=1.10–2.03), change in character of urine (RR=1.42, 95% CI=1.07-1.79), and change in mental status (RR=1.38, 95% CI=1.03–1.74).
CONCLUSION: Dysuria, change in character of urine, and change in mental status were significantly associated with the combined outcome of bacteriuria plus pyuria. Absence of these clinical features identified residents at low risk of having bacteriuria plus pyuria (25.5%), whereas presence of dysuria plus one or both of the other clinical features identified residents at high risk of having bacteriuria plus pyuria (63.2%). Diagnostic uncertainty still remains for the vast majority of residents who meet only one clinical feature. If validated in future cohorts, these clinical features with bacteriuria plus pyuria may serve as an evidence-based clinical definition of UTI to assist in management decisions.     

Prevalence of urinary tract infection during outpatient follow-up after renal transplantation

Summary Seven hundred and twenty-seven renal transplant patients are reviewed with respect to the occurrence of urinary tract infection (UTI) after renal transplantation. UTI was defined as the detection of both bacteriuria (10⁵ CFU/ml) and pyuria (10 leukocytes/hpf). UTI developed in 11 of the inpatients (20.8%) and in 30 (4.2%) of the outpatients during a one-year period. Among outpatients, 12 had symptomatic infections, comprising seven with acute pyelonephritis and five with acute cystitis. Asymptomatic UTI was detected in 18 patients. In addition, asymptomatic bacteriuria without pyuria was observed in ten (1.4%) patients. UTI was more common in patients with diabetes, and underlying urinary tract complications were present in some patients. Administration of trimethoprim-sulfamethoxazole for about 4 months is suggested to reduce the frequency of UTI in the early period after renal transplantation.     

Urine sampling in ambulatory women: midstream clean-catch versus catheterization

We conducted a study to determine if there were any significant differences in urinalyses or urine cultures obtained by midstream clean-catch (MSCC) urine sampling in comparison with in-and-out catheterization (CATH). One hundred five women with symptoms suggestive of a urinary tract infection were studied prospectively. Each woman had a MSCC urine sample obtained initially, followed by a CATH sample. The MSCC and CATH urine samples were analyzed and compared for urine culture, leukocyte esterase, nitrites, microscopic bacteriuria, and pyuria. Of the 105 patients, 42 (40%) had a culture-proven urinary tract infection. The concordance rates between MSCC and CATH urine cultures, nitrites, leukocyte esterase, significant microscopic bacteriuria, and pyuria were 96%, 94%, 93%, 90%, and 90%, respectively. There were no statistically significant differences between MSCC and CATH sensitivities, specificities, or positive or negative predictive values for any urinalysis variable (leukocyte esterase, nitrites, significant microscopic bacteriuria, or pyuria). We conclude that if proper MSCC technique is used, the differences between MSCC and CATH urinalyses or urine cultures do not appear to be significant in the majority of ambulatory women without active vaginal bleeding who present with symptoms suggestive of a urinary tract infection.     

Faropenem 300 mg 3 times daily versus levofloxacin 100 mg 3 times daily in the treatment of urinary tract infections in patients with neurogenic bladder and/or benign prostatic hypertrophy

Faropenem (FRPM) is an only penem antibiotics. Though it has been reported that FRPM had good efficacy (overall efficacy rate: 82.0%) against patients with complicated urinary tract infection, FRPM has not been frequently used for UTI patients. This multicenter clinical study was designed to compare FRPM 300 mg 3 times daily to Levofloxacin (LVFX), which is the standard treatment for patients with UTI, 100 mg 3 times daily for 7 days in the treatment of urinary tract infections in patients with neurogenic bladder and/or benign prostatic hypertrophy. A total of 60 patients with significant bacteriuria and pyuria were included in this study. Overall efficacy rate (excellent plus moderate) was achieved in 90.6% (29/32) of patients treated with FRPM versus 82.1% (23/28) of those treated with LVFX. The ratios of eliminated bacteriuria and cleared pyuria were 71.9% and 56.3% of patients treated with FRPM, and 64.3% and 75.0% of those treated with LVFX. These data were not significant difference. In conclusion, FRPM 300 mg 3 times daily is at least as effective as LVFX 100 mg 3 times daily in patients with complicated urinary tract infection.     

Positive urine cultures: A major cause of inappropriate antimicrobial use in hospitals?

INTRODUCTION

Urine specimens are among the most common samples submitted for culture to microbiology laboratories. The objectives of the present study were to describe the indications for obtaining urine cultures in a cohort of hospitalized patients, and to determine the appropriateness of antimicrobial therapy in response to urine culture results.

METHODS:

The study was performed at a teaching hospital with an adjoining long-term care facility from June 1 to July 31, 2006. The medical records of nonpregnant adult patients with and without bacteriuria were reviewed. A symptomatic urinary tract infection was defined as the presence of bacteriuria in a patient with fever or urinary symptoms; asymptomatic bacteriuria was defined as bacteriuria without urinary symptoms and no infection evident at another site.

RESULTS:

Medical records of 335 eligible patients (64% male; mean age 68 years) were reviewed, including all 137 with bacteriuria, and 198 with negative urine cultures. In total, 51% of the urine specimens were obtained from an indwelling urinary catheter, and 28% were voided urine samples. Confusion (57%) and fever (36%) were the most common indications noted for obtaining the urine cultures. Only 34 patients (25% of those with positive urine cultures) met the criteria for a symptomatic urinary tract infection; 67 (49%) had asymptomatic bacteriuria and 36 (26%) had infection at a nonurinary site. Of those with asymptomatic bacteriuria, 64% received antimicrobial therapy for a total of 347 days. Confused patients with asymptomatic bacteriuria were more likely to be treated than were bacteriuric patients without altered mental status (OR 1.8, 95% CI 1.2 to 4.1; P=0.03).

CONCLUSIONS:

Urine cultures are frequently obtained from hospitalizedpatients,evenintheabsenceofurinarysymptoms.Asymptomatic bacteriuria is often treated in these patients, and accounts for a substantial burden of inappropriate antimicrobial use in hospitals. Effective strategies to improve urine culture ordering and antimicrobial utilization in hospitals need to be implemented.     

Diagnosis and Management of Urinary Tract Infection in Hospitalized Older People

OBJECTIVES: To compare the diagnosis and management of urinary tract infection (UTI) in hospitalized older people with clinical criteria and therapeutic guidelines.
DESIGN: A retrospective case series of emergency hospital admissions collected over an 18-month period.
SETTING: An acute general hospital in northwest England.
PARTICIPANTS: Two hundred sixty-five patients aged 75 and older with a diagnosis of UTI at hospital discharge.
MEASUREMENTS: Data relating to age, sex, presenting complaint, admission and discharge destinations, background comorbidities and medications, investigations performed, treatment given, length of stay, and complications were obtained using chart review.
RESULTS: Of the 265 patients (mean age 85.4) the overdiagnosis of UTI was common, with 43.4% of patients not meeting criteria. Only 32.1% of patients overall had any urinary tract symptoms (48.7% in the UTI group). Of the non-UTI group, 12 (10.4%) had urinary tract symptoms with a negative urine culture, 43 (37.4%) had asymptomatic bacteriuria (ASB), and 60 (52.2%) had neither urinary tract symptoms nor bacteriuria. Treatment given varied greatly. The mortality rate was 6.0%, and the average length of stay was 29.9 days (median 17.0, range 1–192). Complications were frequent, including Clostridium difficile diarrhea (8%), falls (4%), methicillin-resistant Staphylococcus aureus infection (3%), and fracture (2%).
CONCLUSION: More-reliable criteria are needed to aid the diagnosis of UTI in hospitalized older people. Better adherence to clinical management guidelines may improve outcomes.     

Clostridium difficile and vancomycin-resistant enterococcus: the new nosocomial alliance

OBJECTIVES: The aims of this study were to determine the frequency of the association between Clostridium difficile (C. difficile) and vancomycin-resistant Enterococcus (VRE) and delineate the role of C. difficile coinfection as a predictor of VRE infection versus colonization and adverse outcome. METHODS: Patients with both C. difficile colitis and VRE (CD/VRE) were compared to patients with VRE alone with regard to demographics, comorbidity, prior antibiotic therapy, and coinfection with methicillin-resistant Staphylococcus aureus and funguria. C. difficile as a predictor of VRE infection (VRE-I) versus colonization (VRE-C) and adverse outcome was also studied. RESULTS: Eighty-nine patients with VRE infection or colonization were studied. This included 31 cases of VRE-I and 58 VRE-C. C. difficile was isolated in 17 (19.1%) of patients; of these C. difficile was isolated before VRE in 9 patients and after VRE in 8. The two groups did not differ in age, residence, or comorbidity. C. difficile coinfection was not predictive of VRE-I versus VRE-C, nor was it associated with increased length of stay or mortality. However, the mortality rates in both groups was high, around 30%. A significant association was noted between the use of vancomycin and metronidazole (before the isolation of VRE) and C. difficile coinfection (p = 0.03 and p = 0.001, respectively). A high incidence of nosocomial coinfection with methicillin-resistant Staphylococcus aureus, funguria, and gram-negative sepsis was noted in both groups; the association with funguria was statistically significant (p = 0.029). CONCLUSIONS: In conclusion, C. difficile coinfection is common in patients with VRE infection or colonization and is significantly associated with other nosocomial dilemmas like funguria. This may result in the emergence of highly virulent pathogens including vancomycin-resistant C. difficile, posing new challenges in the management of nosocomial diarrheas.     

Infection and colonization with vancomycin-resistant Enterococcus faecium in an acute care Veterans Affairs Medical Center: A 2-year survey

Background: After our first known patient with vancomycin-resistant enterococci (VRE) infection was admitted in 1993, we observed a gradual increase in infections and colonization caused by this organism. Thus we initiated a prospective study to quantitate the incidence of VRE infection versus colonization, to identify risk factors for VRE, and to define the natural history of VRE colonization among our patients. Methods: Stool/rectal cultures were performed for patients admitted to the intensive care units at the time of admission and weekly thereafter. Patients found to be carrying VRE were followed with cultures every 2 weeks, and this protocol was continued after transfer to the medical-surgical wards. A surveillance form was initiated on each VRE patient and included demographics, underlying diseases, and risk factors. Environmental cultures in the intensive care units were randomly performed. Patients with positive cultures were isolated. Results: During a 27-month period, 210 patients were found to be colonized or infected with VRE. Ages ranged from 35 to 97 years; the mean age was 65 years. Fourteen percent (29 of 210) of the patients were VRE positive on admission. Nosocomial colonization or infection occurred at an average of 28 days after admission. Seventeen percent (25 of 216) of patients cleared VRE during their hospital stay; 19% (40 of 210) developed 47 infections. One third of infections involved the urinary tract. Liver transplantation, chemotherapy, and total parenteral nutrition were each associated with infection. Conclusion: Routine measures as advocated by the Centers for Disease Control and Prevention were not effective in controlling VRE in our patient population. (AJIC Am J Infect Control 1998;26:558-62)     

The natural course of uncomplicated lower urinary tract infection in women illustrated by a randomized placebo controlled study

This prospective, multicentre, randomized, double-blind and placebo controlled study was performed to describe the natural course of uncomplicated lower urinary tract infection (UTI). A total of 1143 women 18 y and above, consulting at 18 primary health care centres in northern Sweden for symptoms suggestive of UTI were included. The symptoms urgency, dysuria, suprapubic pain and loin pain were registered, and urine cultures performed at inclusion and follow-up visits 8-10 d and 5-7 weeks later. Associations between all symptoms and bacteriuria or bacterial counts were unpredictable. Eradication of symptoms and bacteriuria and combinations of them were studied in 288 patients placebo treated for 7 d, of whom 39% dropped out after the first follow-up visit. The spontaneous cure rate of symptoms was 28% after the first week, and 37% had neither symptoms nor bacteriuria after 5-7 weeks. Considering the high dropout rate after the first follow-up visit, the spontaneous cure rate of symptoms and bacteriuria was calculated to 24% at the end of study. We conclude that patient near-laboratory tests are required to establish the diagnosis of lower UTI, and the guidelines for diagnosis of UTI need to be revised.     

Patient-initiated treatment of uncomplicated recurrent urinary tract infections in young women.

BACKGROUND: Recurrent urinary tract infections (UTIs) are a common outpatient problem, resulting in frequent office visits and often requiring the use of prophylactic antimicrobial agents. Patient-initiated treatment of recurrent UTIs may decrease antimicrobial use and improve patient convenience. OBJECTIVE: To determine the safety and feasibility of patient-initiated treatment of recurrent UTIs. DESIGN: Uncontrolled, prospective clinical trial. SETTING: University-based primary health care clinic. PARTICIPANTS: Women at least 18 years of age with a history of recurrent UTIs and no recent pregnancy, hypertension, diabetes, or renal disease. INTERVENTION: After self-diagnosing UTI on the basis of symptoms, participating women initiated therapy with ofloxacin or levofloxacin. MEASUREMENTS: Accuracy of self-diagnosis determined by evidence of a definite (culture-positive) or probable (sterile pyuria and no alternative diagnosis) UTI on pretherapy urinalysis and culture. Women with a self-diagnosis of UTI that was not microbiologically confirmed were evaluated for alternative diagnoses. Post-therapy interviews and urine cultures were used to assess clinical and microbiological cure rates, adverse events, and patient satisfaction. RESULTS: 88 of 172 women self-diagnosed a total of 172 UTIs. Laboratory evaluation showed a uropathogen in 144 cases (84%), sterile pyuria in 19 cases (11%), and no pyuria or bacteriuria in 9 cases (5%). Clinical and microbiological cures occurred in 92% and 96%, respectively, of culture-confirmed episodes. No serious adverse events occurred. CONCLUSION: Adherent women can accurately self-diagnose and self-treat recurrent UTIs.     

Prolonged colonization with vancomycin-resistant Enterococcus faecium in long-term care patients and the significance of "clearance".

Little is known about the persistence of colonization with vancomycin-resistant Enterococcus faecium (VRE) in the nononcologic, non-intensive care unit patient. We studied all patients who had VRE isolated on > or =2 occasions of > 1 year apart (Study A) and those who had been "cleared" of VRE colonization after 3 negative stool cultures (Study B). Twelve patients had stored VRE isolates recovered > 1 year apart (Study A), and 58% of paired isolates were genotypically related according to pulsed field gel electrophoresis patterns. In Study B, stool samples were obtained weekly from 21 "cleared" patients for 5 weeks, which revealed that 24% were VRE positive. For these culture-positive patients, 72% of the cultures failed to detect VRE. Recent antibiotic use was significantly more common in the culture-positive patients, as compared with culture-negative patients (P=.003). Colonization with VRE may persist for years, even if the results of intercurrent surveillance stool and index site cultures are negative. Cultures for detection of VRE in stool samples obtained from patients declared "cleared" are insensitive.     

Vancomycin-resistant enterococci in intensive care units: high frequency of stool carriage during a non-outbreak period.

BACKGROUND: We aimed to define the epidemiological associations of vancomycin-resistant enterococci (VRE) in intensive care units (ICUs) during a non-outbreak period by examining prevalence, risk factors for colonization, frequency of acquisition, and molecular strain types. DESIGN: A prospective cohort design was followed. Consecutive patient admissions to 2 surgical ICUs at a tertiary care hospital were enrolled. The main outcome measures were results of serial surveillance cultures screened for VRE. RESULTS: Of 290 patients enrolled, 35 (12%) had colonization with VRE on admission. The VRE colonization or infection had been previously detected by clinical cultures in only 4 of these patients. Using logistic regression, VRE colonization at the time of ICU admission was associated with second- and third-generation cephalosporins (odds ratio [OR] = 6.0, P<.0001), length of stay prior to surgical ICU admission (OR = 1.06, P = .001) greater than 1 prior ICU stay (OR = 9.6, P = .002), and a history of solid-organ transplantation (OR = 3.8, P = .021). Eleven (12.8%) of 78 patients with follow-up cultures acquired VRE. By pulsed-field gel electrophoresis, 2 strains predominated, one of which was associated with an overt outbreak on a non-ICU ward near the end of the study period. CONCLUSIONS: Colonization was common and usually not recognized by clinical culture. Most patients who had colonization with VRE and were on the surgical ICU acquired VRE prior to surgical ICU entry. Exposure to second- and third-generation cephalosporins, but not vancomycin, was an independent risk factor for colonization. Prospective surveillance of hospitalized patients may yield useful insights about the dissemination of nosocomial VRE beyond what is appreciated by clinical cultures alone.     

Blood group non-secretors have an increased inflammatory response to urinary tract infection.

The aim of this study was to assess the possible relationship between secretor state and the inflammatory response to urinary tract infection (UTI). Girls with recurrent UTI were prospectively studied. They included 61 secretor and 23 non-secretor individuals with 604 episodes of recurrent UTI. The response to each UTI episode was measured as the levels of C-reactive protein, erythrocyte sedimentation rate and the body temperature as well as renal concentrating capacity and pyuria. The levels of C-reactive protein, erythrocyte sedimentation rate and the body temperature were significantly higher in non-secretors than in secretors (p less than 0.04). As a consequence, non-secretors had an increased probability of being assigned a diagnosis of acute pyelonephritis rather than asymptomatic bacteriuria (p less than 0.05). The higher inflammatory response in non-secretors was independent of the Gal alpha 1-4Gal beta adhesin expression of the infecting Escherichia coli strains. The increased inflammatory response to UTI in non-secretors might explain the accumulation of these individuals among patients with renal scarring.     

A comparative study of pyuria and asymptomatic bacteriuria in school children

Urine samples were collected from 1,000 school children aged between 4 and 15 years. Twenty-eight children had significant bacteriuria, while 32 had significant pyuria. Seventeen pupils had both significant bacteriuria and pyuria. The study shows that although there is a positive association between pyuria and bacteriuria, the absence of pus cells in urine samples cannot be taken as evidence of absence of bacteriuria, nor can the presence of pyuria alone be considered as an indication of infection. Escherichia coli is the commonest agent in school children with significant bacteriuria.     

The incidence of and clinical variables associated with vancomycin-resistant enterococcal colonization in mechanically ventilated patients

STUDY OBJECTIVES: (1) To determine in our ICU the incidence of vancomycin-resistant enterococcus (VRE) colonization in mechanically ventilated patients without a history of VRE infection or colonization; and (2) to determine the risk factors and outcome variables associated with VRE colonization in these patients. DESIGN: A prospective cohort study conducted between January 1996 and March 1998. SETTING: Medical and cardiac critical care units in a tertiary care urban university hospital. PATIENTS: Mechanically ventilated patients without evidence of pneumonia at the onset of ventilation. INTERVENTIONS: None. MEASUREMENTS AND RESULTS: Patients underwent rectal cultures by standard methods on day 1, day 3 or 4, day 6 or 7, and day 14 of intubation to detect VRE. Thirteen of 83 patients (16%) had rectal cultures positive for VRE (VRE+) at some point while being mechanically ventilated during their stay in the ICU. In comparison, approximately 15 of 2,100 medical ICU patients (0.7%) had clinical VRE infections as determined by the hospital's infection control program during a 2-year period. VRE+ patients had a higher incidence of immunosuppression than patients who had rectal cultures negative for VRE (VRE-) (9 of 13 [69%] vs 16 of 70 [23%], respectively; p < 0.01) and neutropenia (4 of 13 [31%] vs 5 of 70 [7%], respectively; p < 0.01). Hospital length of stay (LOS) was longer in VRE+ patients than in VRE- patients (27+/-17 days vs 17+/-14 days, respectively; p = 0.05), whereas pre-ICU hospital LOS and ICU LOS were similar in both patient groups. Five of 67 patients (7%) were VRE+ on day 1 of intubation, suggesting colonization at a prior site of care. Three of 29 patients who had subsequent rectal cultures converted to VRE+ while in the ICU. This group had a higher incidence of immunosuppression and neutropenia, and received more vancomycin compared with the patients who remained VRE- (p < 0.01). However, there was no significant difference in the use of other broad-spectrum antibiotics (such as antipseudomonal penicillins, third-generation cephalosporins, quinolones, and clindamycin), enteral tube feedings, or sucralfate between the two groups. In addition, a topical antibiotic paste (a gentamicin, nystatin, polymixin slurry) that was placed in the oropharynx to prevent bacterial overgrowth was not found to increase the incidence of VRE colonization in this patient population. CONCLUSIONS: The incidence of VRE colonization was surprisingly high: 16% in mechanically ventilated patients in a hospital in which VRE was not previously known to be endemic. Risk factors for the acquisition of VRE colonization included immunosuppression, neutropenia, and vancomycin use. Increased LOSs and hospital costs were seen in VRE+ patients compared to VRE- patients. Whether VRE colonization is a contributor to severe disease that leads to prolonged hospitalization and increased resource allocation or whether it is simply a marker of disease severity cannot be determined from this study. To the extent that specific antibiotic protocols are used to reduce antibiotic-resistant flora in the ICU, monitoring the incidence of VRE in the stool specimens of immunocompromised, mechanically ventilated patients can be a simple and useful tool to assess one effect of these strategies.     

A comparative study of the mannose-resistant and mannose-sensitive haemagglutinins of Escherichia coli isolated from urinary tract infections

The distribution of mannose-resistant (MRHA) and mannose-sensitive (MSHA) fimbrial haemagglutinins was examined in 482 strains of Escherichia coli isolated from 390 adult women and 45 pregnant mothers with a variety of urinary tract infections (UTI), and from 47 healthy controls. The proportion of MRHA strains was significantly higher in patients with symptomatic UTI (75%) than in women with non-significant bacteriuria (30%, p less than 0.001), pregnant women with asymptomatic UTI (34%, p less than 0.0001) and healthy controls (0%). The proportion of MSHA strains was significantly lower in patients with symptomatic UTI (22%) than in women with non-significant bacteriuria (46%, p less than 0.001) and pregnant women with asymptomatic UTI (52%, p less than 0.01). Only 17% of the strains from healthy controls had MSHA activity. In pregnant women with UTI, whether this was symptomatic or asymptomatic, there was a significant association between infection with MRHA strains of E. coli and a past history of UTI. Thus, in a pregnant woman with an infection and a past history of UTI there is a seven-fold greater chance that this infection is due to an MRHA-bearing organism than in pregnant women without such a history. There was also a significant association between MRHA organisms and symptomatic infection. The risk of symptomatic patients having an infection with an MRHA strain is six times greater than that for a patient with a covert infection.     

Bacteriuria in men infected with HIV-1 is related to their immune status (CD4+ cell count).

OBJECTIVE: Reports from the United States that urinary tract infections (UTI) are more common in homosexual than in heterosexual men have not been confirmed in Europe. The occurrence of several UTI in men infected with HIV-1 has been recorded in The Netherlands. We therefore analysed the relationship between the presence of bacteriuria and the immune status (CD4+ cell count) in these HIV-1-infected patients. DESIGN: Urinary cultures were obtained prospectively for 2 years, during the first visit and every 6 months thereafter, when signs and symptoms of UTI occurred and when patients had fever of unknown origin. CD4+ cell counts were measured at the same time. SETTING: The study was performed at the University Hospital, Utrecht, The Netherlands. PATIENTS, PARTICIPANTS: One hundred and thirty HIV-1-infected men attended our hospital. Data from 98 were analysed. Eighty-nine (91%) of these men were either homo- or bisexual. MAIN OUTCOME MEASURES: Positive urinary culture. RESULTS: Group 1 (CD4+ cell count less than 200 x 10(6)/l) consisted of 47 patients; 30% had at least one period of bacteriuria, with 21 episodes. Group 2 (CD4+ cell count 200-500 x 10(6)/l) consisted of 27 patients; 11% had at least one period of bacteriuria, with five episodes. We did not find bacteriuria in the 24 patients in group 3 (CD4+ cell count greater than 500 x 10(6)/l). The rate of bacteriuria per patient-month, 4 (group 1) versus 2 (group 2), differed significantly (P less than 0.001). A significant relationship between CD4+ cell count and bacteriuria was found (P = 0.00003); no relationship, however, was found with anal intercourse, hospitalization, Karnofsky score, follow-up, or age. CONCLUSION: We conclude that men infected with HIV and presenting with a CD4+ cell count less than 200 x 10(6)/l are at increased risk for bacteriuria.     

Intensified Strategies to Control Vancomycin-Resistant Enterococci in Immunocompromised Patients

Increasing colonization and infection with vancomycin-resistant enterococci (VRE) in immunocompromised patients are associated with increased mortality. Despite contact precautions for VRE control, rapid limitation of its spread is often impossible. We report on a VRE outbreak in a hematologic/oncologic unit including 33 patients. Although 28 of the patients had only VRE colonization, VRE-related infection was probable in 4 patients, and VRE infection of the bloodstream occurred in 1 case. Two patients were identified by VRE screening on admission, 20 were identified by weekly routine VRE screening, and 6 were identified from specimens taken to clarify infections (eg, urine, bronchoalveolar lavage). Five individuals acquired VRE colonization as inpatients (contact patients). Multiple-locus variable-number tandem repeat analysis (MLVA) proved that the outbreak was caused by VanA gene-positive Enterococcus faecium belonging to MLVA genogroup C1(MLVA types 1, 7, 12). The outbreak strains exhibited the potential virulence factor esp(enterococcus surface protein). The outbreak was terminated within 2 months by intensified infection-control measures, including quarantine and the cohorting of patients who tested positive for VRE; however, VRE spread recurred after the measures were discontinued but was again limited by resuming the measures. We conclude that intensive infection-control strategies enable the timely termination of VRE outbreaks, even those involving VRE strains with high epidemic potential on "high-risk wards" (eg, hematologic/oncologic units). Premature discontinuation of infection-control measures may cause recurrence of the VRE spread.     

The association between Staphylococcus aureus bacteremia and bacteriuria

The relationship between Staphylococcus aureus bacteremia and bacteriuria was studied over a five year period in three hospitals. In a Veterans Administration Hospital, 59 patients with Staph, aureus bacteremia had a urine culture within 48 hours of a positive blood culture. In 16 of 59 (27 per cent), greater than 10(5) Staph. aureus was recovered from the urine in pure culture. Six of these patients had apparent primary staphylococcal urinary tract infection. Clinical and laboratory parameters in the patients with staphylococcal bacteremia and bacteriuria were compared with those in 31 patients with staphylococcal bacteremia and sterile urine cultures. The two groups differed only in the more frequent occurrence of pyuria and proteinuria in the bacteriuric patients. In two other hospitals, staphylococcal bacteriuria occurred in 7 per cent of patients with Staph. aureus bacteremia and in 13 per cent of cases of staphylococcal endocarditis. Review of autopsy records for 33 patients who died within one month of their bacteremia failed to show a correlation between bacteriuria and the presence of renal abscess. Staphylococcal bacteriuria is a frequent and unexplained concomitant of Staph. aureus bactremia.