Residual urine in children with acute cystitis and in healthy children: assessment by sonography

Residual urine was assessed by ultrasound in children with single attacks of symptomatic lower urinary tract infection and in healthy controls. Residual urine was found significantly more often in the 39 patients during acute illness as well as during a follow-up of 6 months, compared to 55 control children. Infections caused by P-fimbriated Escherichia coli were not more often associated with residual urine than infections with nonP-fimbriated Escherichia coli or other bacterial species. It is suggested that residual urine is a facilitating host factor among others in the pathogenesis of symptomatic urinary tract infection in childhood.     

Urinary tract infection prophylaxis using Escherichia coli 83972 in spinal cord injured patients

PURPOSE: Escherichia coli 83972 was previously shown to establish bladder colonization in select patient groups. We evaluate the safety and feasibility of using bacterial interference with E. coli 83972 to prevent urinary tract infection in spinal cord injured patients. MATERIALS AND METHODS: A total of 21 men and women with neurogenic bladder secondary to spinal cord injury underwent intravesical inoculation with E. coli 83972. Frequency of symptomatic urinary tract infection before and after colonization was compared. RESULTS: Successful long-term bladder colonization was achieved in 13 study participants. Mean duration of colonization was 12.3 months (range 2 to 40). Subjects had no symptoms of urinary tract infection while colonized with E. coli 83972 (0 infection per 18.4 patient-years). Successfully colonized subjects had experienced a mean of 3.1 symptomatic urinary tract infections per year (range 2 to 7) before colonization. Symptomatic infection also occurred in 4 subjects who were not successfully colonized with E. coli 83972 and in 7 others after spontaneous loss of colonization. Colonized subjects reported subjective improvement in quality of life with respect to urinary tract infection while colonized. CONCLUSIONS: E. coli 83972 may be safely used to establish long-term asymptomatic bladder colonization in spinal cord injured subjects. Preliminary findings suggest that colonization with E. coli 83972 may reduce the frequency of urinary tract infection in patients with neurogenic bladder secondary to spinal cord injury.     

Lack of correlation of P blood group phenotype and renal scarring

Renal scarring is in most instances caused by infection in the young child. The most commonly occurring etiological agent in urinary tract infections is Escherichia coli. An important virulence factor for these nephropathogenic E. coli is the ability to adhere to urinary tract epithelium. This adhesion is often mediated by P-fimbriae, which recognize and specifically bind to the receptor structure (alpha-D-Galp-(1-4)beta-D-Galp) present on the cell membranes of human urinary tract epithelium. This carbohydrate structure occurs as an entity of the glycosphingolipids that correspond to the antigens of the human P blood group system. It has been proposed recently that children with recurrent acute pyelonephritis have a higher frequency of the P1 blood group phenotype than the expected 75%. We have studied 56 adult female patients with a history of febrile urinary tract infection and signs of renal scarring on urogram. The P blood group phenotype was determined in all patients. There was no increase of the P1 blood group phenotype in the patients with verified renal scarring. In conclusion, our results do not support a role of the P1 blood group phenotype in the pathogenesis of renal scarring due to previous febrile urinary tract infection.     

Urinary tract infection in boys

Considerable literature exists regarding the evaluation and treatment of children with urinary tract infection yet little has been reported solely about boys. We reviewed retrospectively 83 boys who were seen after an initial urinary tract infection. Fever was the most common presenting sign (50 per cent) and the most common organisms encountered were of the gram-positive group of bacteria. Escherichia coli accounted for only 21 per cent of the infections. Of the boys 75 per cent (62 patients) had an anatomic abnormality, most commonly vesicoureteral reflux, although more than 25 per cent of our patients had obstructive lesions. Renal scarring was present in half and 58 per cent required early surgical intervention. Urinary tract infection seems to have a higher morbidity in boys and the finding of an atypical organism is to be expected. Based on our findings, we strongly recommend an excretory urogram and a voiding cystourethrogram as the minimal evaluation of boys following an initial urinary tract infection.     

Urinary tract infection in pediatric renal transplantation

Urinary tract infection is a frequent complication following renal transplantation and represents a potential focus for systemic infection in the immunosuppressed transplant recipient. The incidence, etiologic factors, temporal pattern, bacteriology, and prognostic significance of urinary tract infection were determined by analysis of 85 renal allografts in 69 patients. Significant bacteriuria occurred after 49 of 85 transplants (58 per cent). The incidence of infection was not related to success or source of the allograft, but was related to patient gender. Urinary tract infections developed in 68 per cent of females, while only 43 per cent of males became infected (p < 0.05). Escherichia coli caused most first infections (30 per cent), while Pseudomonas aeruginosa and E. coli were equally responsible for recurrent infections (25 per cent each). Children with previous reconstructive urologic surgery had similar allograf success (63 per cent) and infection rates (53 per cent) as our other children (61 per cent and 58 per cent, respectively). No apparent correlation was noted between episodes of infection and graft rejection. Thorough preoperative assessment and preparation and prompt, specific treatment minimize the adverse influences of urinary tract infection.     

Urinary tract infection after renal transplantation

Eighty-eight patients with cadaver and living donor kidney transplants and the incidence of urinary tract infections over a long-term follow-up period are reviewed. Urinary tract infections developed in 28 per cent of the 88 patients after renal transplantation, and 72 per cent of these infections developed within the first month of transplantation. Only 43 per cent of the infecting organisms were Escherichia coli. Forty-seven per cent of the patients with recurrent urinary tract infections had pyelonephritis or polycystic kidneys as their original renal disease. The morbidity rate in our patients with recurrent urinary tract infections was minimal.     

Long-term prophylaxis of urinary infections in women: comparative trial of trimethoprim, methenamine hippurate and topical povidone-iodine

We randomized 64 patients with a history of recurrent urinary tract infections among 3 regimens of long-term (1 year) prophylactic treatment: 20 were given 100 mg. trimethoprim at night, 25 received 1,000 mg. methenamine hippurate every 12 hours and 19 were asked to cleanse the perineum (especially the periurethral area) twice daily with povidone-iodine solution. The progress of patients in terms of urinary symptoms and/or bacteriuria, changes in periurethral flora, side effects, and hematological and biochemical profiles was followed at regular intervals. All treatments were effective in reducing the incidence of symptomatic attacks when compared to the 12 months immediately before therapy and there was little to choose between the individual regimens on this account. However, trimethoprim was tolerated better than were the other 2 treatment regimens. In the group given trimethoprim most of the breakthrough infections (71.4 per cent) that occurred were caused by trimethoprim-resistant organisms (usually Escherichia coli), while in the other 2 groups the incidence of trimethoprim-resistant organisms causing infection was low (2.7 per cent). Treatment with trimethoprim reduced significantly the periurethral colonization of Escherichia coli.     

Urinary tract infection in oliguric patients with chronic renal failure

We studied 182 patients with chronic renal failure by urinalysis and urine cultures. Of the patients 27 per cent had significant bacteriuria (more than 10(5) per ml.), 38 per cent had significant pyuria (more than 10 white blood cells per high power field), 19 per cent had urinary tract infection and 7 per cent had symptomatic urinary tract infection. All 12 patients with symptomatic urinary tract infection had significant bacteriuria and 11 had significant pyuria, while 1 had 5 to 10 white blood cells per high power field. Incidences of urinary tract infection differed depending on the primary renal disease (12, 13, 41 and 67 per cent for chronic glomerulonephritis, diabetic nephropathy, polycystic kidney and chronic pyelonephritis, respectively). Among the patients with chronic glomerulonephritis no significant differences were seen in frequencies of bacteriuria and urinary tract infection between male and female patients or between those who did and did not undergo hemodialysis. Also, no significant correlation was seen between bacteriuria and daily urine output but pyuria was significantly more frequent in oliguric patients or those on hemodialysis.     

Complications of chronic indwelling urinary catheters among male nursing home patients: a prospective study

We studied prospectively the incidence of symptomatic infections of presumed urinary tract origin requiring antimicrobial therapy among 54 male nursing home patients with chronic indwelling bladder catheters. During 514 patient-months at risk there were 106 episodes of symptomatic infection, for an incidence of 0.21 per patient-month at risk. Of the patients 80 per cent had at least 1 episode and 48 per cent had 2 or more. None of the clinical factors we examined, including age, nutritional status, stool incontinence, diabetes mellitus, episodes of catheter blockage and the use of chronic suppressant antimicrobial therapy, was associated with the development of symptomatic infection. Further research on host and pathogen-related factors that increase the risk for symptomatic infection, and improvements in infection control and catheter care protocols are necessary to decrease catheter-associated morbidity among male nursing home patients who must be managed by chronic indwelling catheterization.     

Selective use of excretory urography in women with acute pyelonephritis

The outcome of excretory urography was analyzed in 103 nonpregnant women followed prospectively after community acquired acute pyelonephritis. Radiological abnormality was found in 40 per cent of the patients (17 per cent had major abnormalities, including renal scarring, calculi and obstruction). All 5 women with surgically correctable lesions had rapid bacteriological relapse or recurrent acute pyelonephritis. Neither a history of urinary tract infection, the acute inflammatory response nor infection due to Escherichia coli with or without adhesins specific for Gal alpha 1----4Gal beta-containing receptors was efficient in predicting major radiographic lesions or the outcome of treatment. Bacteremia was detected in 27 per cent of the patients but in the absence of obstruction. These results suggest that excretory urography is dispensable in most women with acute pyelonephritis, and that those needing such investigation may be identified by failure to respond to antibiotic treatment or by the recurrence pattern.     

Host-parasite relationships in acute pyelonephritis

During a 1-year prospective study, a total of 15 patients (seven children and eight adults) were observed with acute nonobstructive pyelonephritis. P-fimbriated Escherichia coli was the causative pathogen in all 15 patients. The same serotype of E coli that was P-fimbriated was isolated from the vaginal introitus of 60% and from the fecal flora of 86% of these patients. The only host abnormality was moderate vesicoureteral reflux in 20% of the patients. Uroepithelial cells were isolated from the first morning-voided urine from patients, who had recovered from pyelonephritis, and from age-matched controls. Using fluorescein-labelled type 1 and P-fimbriated reference strains of E coli and fluorescence-activated cell sorting (FACS) analysis, we evaluated their ability to adhere to these uroepithelial cells. P-fimbriated E coli was more adherent than type 1 fimbriated E coli, and more P-fimbriated E coli adhered to the patients' cells. Our data show that both colonization with P-fimbriated strains of E coli and receptor availability are important in the pathogenesis of pyelonephritis.     

A five-year prospective follow-up of women with non-obstructive pyelonephritic renal scarring

Fifty women with pyelonephritic renal scarring were prospectively followed for five years and the changes in renal function were related to blood pressure control, plasma renin activity, urinary albumin excretion and the incidence of urinary tract infections (UTI). Five patients (10%) developed end stage renal disease. All these patients had bilateral disease, proteinuria and anti-hypertensive treatment at presentation. The mean +/- SD glomerular filtration rate (GFR) of all patients with renal scarring was 74 +/- 27 ml/min x 1.73 m2 at presentation which was significantly lower than the GFR in 55 patients with a recent episode of acute pyelonephritis (p less than 0.001) and 10 healthy controls (p less than 0.001). GFR and age corrected GFR decreased significantly during follow-up (p less than 0.001) and p less than 0.02 respectively). The decrease in GFR was significantly higher in patients with bilateral scarring, in patients on blood pressure treatment and in patients with an episode of symptomatic UTI during follow-up. Eight patients (16%) had antihypertensive treatment at presentation and another 11 patients (26%), of whom 10 had bilateral scarring, developed hypertension (greater than 140/90 mmHg) during follow-up. Seventy-five per cent of all patients had symptomatic UTI and 40% had an episode of acute pyelonephritis during follow-up. In conclusion, patients with pyelonephritic scarring have a high incidence of UTI and are at high risk of developing renal failure and hypertension. It is essential that recurrent episodes of symptomatic UTI are treated promptly and that blood pressure is monitored carefully in these patients.     

Biochemical fingerprinting of urinary Escherichia coli causing recurrent infections in women with pyelonephritic renal scarring.

A biochemical fingerprinting system, especially designed for subtyping of Escherichia coli and suitable for screening large number of bacterial strains was used in a long-term follow-up study of 19 women with non-obstructive pyelonephritic renal scarring and recurrent urinary infections in order to examine whether recurrent infections mostly are relapses or reinfections in this group of patients. Seventy-six recurrent infections occurred during a 47-month follow-up (0.09 infections per observation month). The majority of the recurrences were reinfections (58/76, 76%) and 18 (24%) were relapses caused by E. coli. Approximately 50% of relapses and reinfections caused by E. coli were symptomatic while the majority of reinfections caused by other bacteria were asymptomatic (23/30, 77%). In one patient a relapse of E. coli infection occurred more than two years (745 days) after the initial infection. Reinfections may occur early (7 days) after cessation of antimicrobial therapy in this group of patients. Two patients had an episode of symptomatic bacteriuria 51 and 56 days after asymptomatic bacteriuria with the same E. coli strain was detected. Biochemical fingerprinting of the E. coli isolates revealed that they belong to a wide variety of biochemical phenotypes which indicates that they are not members of widespread uropathogenic clones.     

Adhesiveness to urinary tract epithelial cells of fecal and urinary Escherichia coli isolates from patients with symptomatic urinary tract infections or asymptomatic bacteriuria of varying duration.

Adhesiveness to human urinary tract epithelial cells was high for Escherichia coli strains isolated from patients with acute pyelonephritis and acute cystitis, and low for asymptomatic bacteriuria strains detected at screening. Escherichia coli bacteria causing asymptomatic reinfections, detected near the onset of bacteriuria, adhered more than those detected at screening. No difference in the adhesive ability was found between fecal isolates of the strain causing urinary tract infection, isolated at or before onset of bacteriuria, and the urinary strain in symptomatic or asymptomatic patients. Normal fecal Escherichia coli from non-bacteriuric patients adhered less than all other strains tested.     

New Renal Scars in Children With Urinary Tract Infections, Vesicoureteral Reflux and Voiding Dysfunction: A Prospective Evaluation

Purpose

Established renal scarring represents areas of the kidney that imaging reveals to be damaged at presentation for medical management of urinary tract infection. New renal scarring represents new renal damage in parts of the kidney that imaging reveals to be normal at presentation. We attempted to characterize patients in whom new renal scars developed while they were under our care.

Materials and Methods

In 1988 a data base was started to identify patients with new renal scarring. All patients presenting with urinary tract infections were enrolled. Our data base has 250 possible fields per event with multiple events per patient. More than 2,100 patients have been enrolled to date. All patients with pyelonephritis, defined as a febrile urinary tract infection with flank pain and tenderness, and all with reflux underwent dimercapto-succinic acid (DMSA) scan at least 4 months after presenting with infection to assess established renal scars. New renal scars were identified when new renal defects were demonstrated on a second DMSA scan.

Results

In our data base there are 1,426 patients with urinary tract infections, 685 (46%) with pyelonephritis and 1,062 (74.5%) with vesicoureteral reflux, including 558 found to have bilateral vesicoureteral reflux and 504 diagnosed with unilateral reflux. A history of daytime urinary incontinence was noted in 538 patients (37.7%), 192 (13.5%) had established scars at initial presentation and in 31 (2.1%) new renal scars developed while they were under our care, including 30 with established scars as well. Of the 25 patients in whom new renal scars developed while on medical therapy 11 underwent surgery. In 6 patients with dysfunctional voiding who were receiving medical treatment renal scars developed postoperatively. Surgery was performed in 17 of the 31 patients and 24 (77%) with new renal scars had a history of dysfunctional voiding.

Conclusions

Previous characterizations of patients with new renal scars have relied on excretory urography for assessing renal architecture and ignored voiding patterns of the children affected. Using the DMSA scan we identified 31 children with reflux, urinary tract infection and dysfunctional voiding in whom new renal scars developed while they were under our care.     

Urinary infection,reflux and renal scarring in females continuously followed for 13–38 years

This study describes the pattern of urinary tract infections (UTI) in 87 females prospectively followed for a median of 23 years from their first recognized symptomatic infection in childhood. At 16 years of age they were selected for follow-up into adulthood because of renal scarring (reflux nephropathy) in 45 and recurrent UTI in 42. The attack rate (number of urinary tract infections per individual per observation year) was highest during the 1st year of life (1.9), with a gradual decrease to the lowest rate (0.2) at age 11–15 years. A moderately increased attack rate (0.4), was seen in the late teens, extending through to the mid twenties. The proportion of infections having a pyelonephritic character decreased with age and number of infection episodes, but not in females with severe renal scarring. Pyelonephritic infections were correlated with vesicoureteric reflux, and renal scarring to low age at the index infection, total number of pyelonephritic episodes and reflux. Females with renal scarring continued to have a high proportion of pyelonephritic recurrences after 10 years of age, implying that they risk progressive renal disease and should be closely followed into adulthood.     

Isolation of anaerobic organisms from kidney in serious renal infections

We have studied 45 patients who underwent nephrectomy owing to unilateral renal sepsis for anaerobic and aerobic bacterial growth in the urine and kidney. Anaerobic organisms were recovered from 11 patients: 10 had positive kidney cultures, and only 1 had positive kidney and urine cultures. There was a distinct relationship between anaerobic infection of the kidney and urinary tract obstruction: 44 per cent of the obstructed kidneys yielded anaerobic organisms versus only 11 per cent of the unobstructed kidneys. Bacteroides fragilis was the anaerobic organism most often cultured. It is suggested that cultures for anaerobic organisms be performed together with aerobic cultures in patients with symptomatic upper urinary tract infections associated with urinary obstruction. In patients in whom anaerobic infection is suspected, in spite of negative anaerobic cultures, antibiotic treatment for anaerobes should be added to the existing therapeutic measures.     

Urinary tract infection in percutaneous surgery for renal calculi

Percutaneous extraction of renal stones is associated with a risk of infection, which sometimes can be severe as a result of the intraoperative introduction of a ureteral catheter, the nephroscopy itself and the fact that a nephrostomy tube sometimes is left in place. It generally is accepted that patients with a preoperative urinary tract infection should be covered during the operation by an appropriate antibiotic. However, the need for routine prophylactic antibiotic treatment in patients with sterile urine preoperatively still is a subject of debate. We report the bacteriological results of 126 cases of percutaneous extraction of renal stones. Of the patients 107 had sterile urine preoperatively and deliberately did not receive prophylactic antibiotics so that the mechanisms of urinary tract infection after percutaneous nephrolithotomy could be studied. Of these patients 37 (35 per cent) suffered a postoperative urinary tract infection, usually owing to Escherichia coli, streptococcus or staphylococcus. The responsible organism was isolated in the bladder urine only in 22 cases, in the nephrostomy tube in 2 and in both sites in 13. Eleven patients (10 per cent) presented with a fever of 38.5C or more. All of the infected patients received appropriate antibiotic therapy and there were only 2 bacteriological failures on long-term followup (5 per cent). A total of 19 patients had a urinary tract infection preoperatively. All 19 patients received appropriate antibiotic therapy starting at least 24 hours preoperatively and continuing for a minimum of 3 weeks. Five patients (26 per cent) presented with a fewer but there were no serious septic complications. All of the patients were discharged from the hospital with sterile urine and there was only 1 long-term bacteriological failure (5 per cent). Both patients with Pseudomonas infection were cured. The risk of clinical infection following percutaneous nephrolithotomy is low despite the fact that 35 per cent of the patients have bacteriuria postoperatively, provided a careful bacteriological examination is performed preoperatively and the patients with urinary tract infection are treated appropriately. These results are in favor of short-term prophylactic antibiotics adapted to the bacterial ecology.     

P-fimbriated Escherichia coli and serum antibody responses to P-fimbriae in pregnant women with urinary tract infections and their children

Escherichia coli (E. coli) is still a major pathogen in urinary tract infections (UTI). It was found that 15 out of 20 cases (75%) of E. coli related UTI were caused by P-fimbriated E. coli, compared to the mere 15% of E. coli isolated from urine and 22% from the stool of healthy controls that were P-fimbriated. All patients studied were pregnant women and their delivered children. Antibody responses to P-fimbriae in the sera of these patients were detected with enzyme-linked immunosorbent assay (ELISA) using purified P-fimbriae. Positive antibody responses were observed at titers of 800-6400 in 8 out of 9 cases of UTI of pregnant women caused by P-fimbriated E. coli. The high level of antibody titers persisted for one month on average and then decreased. These antibodies to P-fimbriae were essentially IgG and transmitted to delivered children from UTI mothers. Therefore, the protective role of these antibodies from P-fimbriated E. coli infections in new born children has been suggested.     

Long-term followup of 103 patients with bladder exstrophy

We reviewed 103 patients with exstrophy of the bladder. Followup was more than 15 years in 51 patients. Initial management consisted of primary bladder closure in 32 patients and urinary diversion in 71. Urinary continence, renal function, urinary tract infections and development of malignant lesions were evaluated. Factors leading to success or failure were analyzed. Although the highest continence rate (83 per cent) was achieved in 40 patients with ureterosigmoidostomy, renal functional deterioration was highest in this group, with 70 per cent of the evaluable renal units being abnormal. Furthermore, 10 per cent of this group died of renal failure and 23 per cent lost 1 kidney each. In 26 patients with an ileal conduit 69 per cent of the renal units evaluated were abnormal. Only 1 patient died of renal failure but 27 per cent lost 1 kidney each. Of 32 patients with primary bladder closure 31 had preservation of renal function. Twelve of 18 patients (67 per cent) in whom vesical neck reconstruction had been completed had total urinary continence and 3 (17 per cent) had partial continence. The incidence of significant urinary tract infections was highest in the ureterosigmoidostomy group (63 per cent) and next to the highest in the ileal conduit group (48 per cent). Malignant lesions developed in 8 patients (8 per cent).