Localization of urinary tract infection in elderly, institutionalized women with asymptomatic bacteriuria

We determined the site of urinary tract infection in 51 elderly, institutionalized women (mean age, 80.5 years) with asymptomatic bacteriuria by using the Fairley bladder washout technique. Thirty-four (67%) infections were localized in the kidney and 17 (33%) in the bladder. Women with renal infection were older than those with bladder infection (81.9 vs. 77.6 years of age; P = .04). The antibody-coated bacteria test had a sensitivity of 58%, specificity of 71%, positive predictive value of 82%, and negative predictive value of 43% for upper-urinary-tract infection. A quantitative urinary leukocyte count of greater than or equal to 20 leukocytes/mm3 had a positive predictive value of 80% and a negative predictive value of 88% for upper-urinary-tract infection. This study suggests that the majority of elderly, institutionalized women with asymptomatic bacteriuria have upper-urinary-tract infection. Both the antibody-coated bacteria test and the quantitative urinary leukocyte count may be useful as noninvasive tests for localization of urinary tract infection in this population.     

The relationship of antibody-coated bacteria to clinical syndromes as found in unselected populations with bacteriuria.

In selected patients, detection of antibody-coated bacteria (ACB) in voided urine has correlated with upper urinary tract infection. From unselected patients, we studied 350 consecutive urine specimens submitted to the diagnostic laboratory with colony counts greater than or equal to 10(5)/ml. In 19% (55) among 288 specimens selected for final analysis ACB occurred. There were no substantial differences in the occurrence of ACB by age or sex of patients or by species of bacteria. The relationship of ACB to clinical syndromes was: asymptomatic bacteriuria, 15% (27/178); cystitis, 8% (6/75); acute hemorrhagic cystitis, 67% (4/6); prostatitis, 67% (2/3); and acute pyelonephritis, 62% (16/26). Among seven clinical findings, only structural abnormalities of the upper urinary tract correlated with the presence of ACB. Failure of fever and leukocytosis to correlate with ACB probably reflected the presence of other associated primary medical or surgical conditions.     

The presence of antibody-coated anaerobic bacteria in asymptomatic bacteriuria during pregnancy.

Quantitative anaerobic culture of urine samples obtained from 593 pregnant women by suprapubic bladder aspiration was performed to establish the involvement of anaerobic bacteria in asymptomatic urinary tract infections. The fluorescent antibody (FA) test was applied to the sediments of bladder aspirates to determine the site of infection. Anaerobic bacteriuria (greater than or equal to 10(4) microorganisms/ml of urine) was found in 34 patients, of whom five were FA-positive. These anaerobes were identified as Lactobacillus minutus, Veillonella parvula (two patients). Clostridium putrefaciens, and Peptostreptococcus anaerobius. Aerobic bacteriuria (greater than 10(4) microorganisms/ml of urine) was detected in 27 patients, of whom 13 were FA-positive. In 10 women with mixed aerobic/anaerobic bacteriuria, no FA-positive bacteria were found. The finding of FA-positive anaerobes may indicate that these organisms are involved in silent renal infection.     

Prognosis in pyelonephritis: promise or progress?

Prognosis in pyelonephritis, or upper urinary tract infection, is provided. This infection is not responsible for progressive renal disease in young or elderly patients but accounts for frequent febrile episodes in women of all ages and men after the age of 50. Vigorous local immune response develops with the infection, which never succeeds in eradicating bacteria but does limit the infection and provides a diagnostic test: the antibody-coated bacteria test. Emphasis is placed on the need for a localization test for upper tract infection because studies based exclusively on clinical criteria are invalid. Appropriate therapy for mildly ill patients is given with recommendations of combination therapy for severely ill persons. Long-term follow-up is critical because most patients with recurrent infections can be given preventive therapy without subjecting them to needless urologic evaluation.     

Role of fimbriated Escherichia coli in urinary tract infections in adult women: correlation with localization studies

The prevalence of uropathogenic Escherichia coli bearing type 1 and/or p fimbriae was assessed in 179 adult women with urinary tract infections, and the presence of specific fimbriae types was correlated with results of localization studies. E. coli with p fimbriae occurred more frequently in patients with clinically defined pyelonephritis (13 of 23 [57%]) than in women with cystitis (22 of 116 [19%]; P = .0004) or asymptomatic bacteriuria (6 of 40 [15%]; P = .0008), whereas organisms with type 1 fimbriae were equally distributed in these three patient groups. In contrast, the presence of p-fimbriated strains was not correlated with infection localized to the upper urinary tract by either the antibody-coated bacteria technique (among symptomatic women) or ureteral catheterization (among asymptomatic women). Thus although p fimbriation seems to be an important virulence factor associated with development of acute pyelonephritis in adult women, its detection appears not to be a useful localization test per se, and efforts to prevent these infections should not be directed against this factor alone.     

Urinary tract infection caused by Corynebacterium group D2: report of 82 cases and review

Corynebacterium group D2 (CGD2) is a slow-growing, urea-splitting, multiantibiotic-resistant microorganism that is frequently isolated from urine samples and that, in certain circumstances, produces infection of the lower urinary tract (acute and chronic cystitis) and the upper urinary tract (pyelonephritis). This paper analyzes (by means of a retrospective and partially prospective clinical protocol) our experience with 82 patients with CGD2 bacteriuria. The infection was symptomatic in 62% of cases, and the clinical diagnoses included acute and chronic cystitis and pyelonephritis with or without bacteremia. Because CGD2 infection of the urinary tract may require specific antimicrobial treatment and because CGD2 is a fastidious microorganism, we recommend prolonged incubation of urine cultures (up to 48-72 hours), especially if the routine culture is negative, when patients are symptomatic, have alkaline urine, or have struvite crystals in the urine sediment.     

Significance of antibody-coated bacteria in urinary sediment in experimental pyelonephritis.

The sequential appearance of antibody-coated bacteria in urinary sediment was followed in experimental pyelonephritis produced with Escherichia coli O6:K13:H1. It was possible to determine against which antigen of the organism this antibody was directed. Antibody-coated bacteria appeared by day 11 of infection, a time which coincided with the synthesis of local (intrarenal) antibody. Bacteria coated with antibody more than three days after serum antibody but four days before urinary antibody appeared. Antibody eluted from coated bacteria was directed against the O-antigen of the infecting organism but not the K-antigen. Newly synthesized intrarenal antibody and urinary antibody were directed only against O-antigen, but not against K-antigen; this finding would explain why the antibody that coated the bacteria was antibody to lipopolysaccharide. Thus, a positive test for antibody-coated bacteria indicates that a local immune response to O-antigen has occurred. It is postulated that this immune response could relate to the clinical symptomatology of acute symptomatic pyelonephritis since most patients presenting with acute pyelonephritis have bacteria coated with antibody.     

Acute renal failure in adults with uncomplicated acute pyelonephritis: case reports and review.

Acute renal failure is a rare complication of acute pyelonephritis in patients who do not have urinary obstruction. Although urinary tract infections are common in adults, pyelonephritis is rarely considered in the differential diagnosis of acute renal failure nor is renal failure considered a likely consequence of bacteriuria. In this review, the cases of acute renal failure caused by acute pyelonephritis that have been reported in the last quarter century are examined. Including two new cases reported, only 12 cases of acute pyelonephritis resulting in acute renal failure were found. Three of these occurred in patients with a solitary kidney. All cases occurred in individuals who had no history of urinary tract infections, and all were caused by Escherichia coli. In several cases, the administration of non-steroidal antiinflammatory drugs contributed to disease. Three cases occurred after catheter-acquired bacteriuria. Acute renal failure is an uncommon but serious consequence of uncomplicated acute pyelonephritis in adults.     

Clinical evaluation of SD-8828 (antibody coated bacteria assay kit) in urinary tract infection]

Clinical usefulness of a newly developed assay kit for ACB (SD-8828) which detects urinary bacteria coating IgG was evaluated and compared to the enzyme antibody plate method. A total of 48 patients including 20 patients with acute simple cystitis and 28 patients with acute or chronic pyelonephritis, who were shown to have pyuria of at least 5 cells/HPF, bacteriuria of at least 10(4) CFU/ml were enrolled in this study. By enzyme antibody method. ABC was positive in 92.9% of patients with upper urinary tract infection and negative in 100% of patients with lower UTI, this difference being statistically significant (p < 0.02). By SD-8828, 85% of positive coincidence rate and 100% of negative coincidence rate, compared to the enzyme antibody technique, was obtained. The overall coincidence rate was high (91.7%). This SD-8828, a new simple assay for ACB, which detects IgG alternating the plate method, may be used as a convenient method in clinical practice.     

Detection of antibody-coated bacteria in children with urinary tract infections

Summary The demonstration of antibody-coated bacteria in urine is a valuable supplementary test for localizing urinary tract infections. When interpreting the results the age of a child, however, is also an important factor. In babies, acute pyelonephritis is often not accompanied by antibody-coated bacteria in the urinary sediment. In chronic pyelonephritis an important factor is the stage of the disease since no antibody-coated bacteria have been detected with bacteriuria in the latent phase. Urine to be tested for the presence of antibody-coated bacteria must be collected in a sterile fashion. No diagnostic value can be attached to a positive result unless this prerequisite has been met.

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Über den Nachweis von antikörperbeladenen Bakterien bei Kindern mit Harnwegsinfektionen

Zusammenfassung Der Nachweis von antikörperbeladenen Bakterien im Urin ist eine der wichtigen Ergänzungsmethoden, die zur Lokalisationsbestimmung einer Harnwegsinfektion verwendet werden kann. Bei der Interpretation der Ergebnisse muß das Alter des Kindes in Betracht gezogen werden, da die Autoren bei einer Vielzahl von Fällen mit akuter Pyelonephritis im Säuglingsalter keine antikörperbeladenen Bakterien nachweisen konnten. Bei der chronischen Pyelonephritis ist gleichfalls die augenblickliche Aktivität von Wichtigkeit, da bei einer Bakteriurie während der Ruhephase keine antikörperbeladenen Bakterien zu beobachten sind. Zum Nachweis antikörperbeladener Bakterien im Sediment muß der Urin steril entnommen werden. Nur unter dieser Voraussetzung ist ein positives Ergebnis diagnostisch verwertbar.

     

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.     

Comparison of urine and serum concentrations of interleukin-6 in women with acute pyelonephritis or asymptomatic bacteriuria.

The mucosal and systemic interleukin-6 (IL-6) response to urinary tract infection was analyzed in women with acute pyelonephritis or asymptomatic bacteriuria. Urine and serum samples were obtained at diagnosis and after treatment. IL-6 activity was elevated in urine samples from most bacteriuric women, regardless of the severity of infection. Urinary levels greater than 20 units/mL occurred in 25 of 29 women with acute pyelonephritis and in 36 of 42 women with asymptomatic bacteriuria. Elevated serum IL-6 levels were found mainly in patients with acute pyelonephritis: Levels greater than 20 units/mL occurred in 14 of 28 women with acute pyelonephritis compared with 0 of 28 women with asymptomatic bacteriuria. These results suggest that bacteriuria is accompanied by elevated urinary IL-6 levels and that this IL-6 is locally produced. The spread of IL-6 to the circulation in patients with acute pyelonephritis may contribute to the elevation of fever and C-reactive protein characteristic of the disease.     

Virulence-associated traits in Escherichia coli causing first and recurrent episodes of urinary tract infection in children with or without vesicoureteral reflux

Virulence-associated properties of 606 urinary isolates from 174 children with urinary tract infections were related to severity of infection and factors increasing host susceptibility, e.g., vesicoureteral reflux (grade II or higher) and P1 blood group phenotype. A high proportion of strains of Escherichia coli causing first or recurrent episodes of acute pyelonephritis in children without reflux expressed the previously noted high frequency of certain O antigens, resistance to serum killing, hemolysin production, and adhesive capacity. A significantly lower frequency of these traits and a higher frequency of non-E. coli were seen among isolates from children with pyelonephritis and reflux, cystitis, and asymptomatic bacteriuria. Reflux was thus found to be a determinant of the level of infection and of the bacterial properties required to produce pyelonephritis. Efforts aimed at preventing or treating urinary tract infection by interfering with "virulent" bacteria may be of less value in patients with recurrent pyelonephritis and reflux, who are most likely to develop renal scars.     

Diuresis bacteriuria in physically dependent elderly women

Among 34 women aged 74-96 years, residents of a Home for the Aged, with reduced mobility and repeatedly negative urine cultures, 16 (47%) responded to a rapid hydration and 20 mg frusemide administered intravenously with a transient bacterial excretion usually trailing the diuresis. Antibody-coated bacteria were detected in 11 of the 13 Gram-negative isolates tested. Women with urine turning positive had significantly lower glomerular filtration rates and more advanced renal tubular defects than the steadily nonbacteriuric subjects of the same age. Progress to renal insufficiency was somewhat faster and all-causes mortality at 1 year was higher in subjects with urine turning positive. Diuresis bacteriuria originating from the upper urinary tract along with frank bacteriuria may be detected in up to 70% of women in their mid-80s and represents a likely source of the most common infection in man's last period of life.     

Iatrogenic emphysematous pyelonephritis in a renal transplant patient

Abstract: Emphysematous pyelonephritis (EPN) is a rare condition that typically occurs in patients with diabetes mellitus, urinary tract obstruction, or immunosuppression such as solid organ transplant recipients. It has high mortality and frequently requires nephrectomy to achieve cure, although percutaneous drainage has been reported to be successful in some patients. We report a renal transplant recipient with underlying diabetes mellitus who developed iatrogenic EPN. The patient initially presented with dyspnea and was admitted for cardiac evaluation. There was no evidence of urinary tract infection at the time of admission. The patient developed high‐grade fever 3 days after admission. Despite intravenous (IV) antibiotic therapy, the patient developed acute renal failure requiring hemodialysis. Studies revealed Klebsiella bacteremia and EPN. We believe that urinary tract infection was precipitated by urinary bladder catheterization performed on the day of admission. Despite 2 weeks of IV antibiotic therapy, infection persisted with progressive extension of gas into the perinephric space on repeat imaging. The patient underwent a transplant nephrectomy with subsequent clinical recovery. This case illustrates that antibiotics alone are often inadequate to cure and preserve renal function in EPN despite immediate therapy. Furthermore, this patient underscores the risk of serious infection precipitated by urinary bladder catheterization in immunocompromised patients.     

Role of urease in pyelonephritis resulting from urinary tract infection with Proteus.

The role of urease in induction of pyelonephritis was studied by treatment of proteus-infected rats with acetohydroxamic acid, a potent inhibitor of urease. Infection was produced by introduction of Proteus mirabilis into the bladder along with a zinc disk. Controls were treated identically but received no acetohydroxamic acid. The number of bacteria per milliliter of urine was the same in both groups. The number of bacteria in the kidneys and the extent of renal damage was much greater in controls. Common enterobacteraceal antigen was not detected in the renal parenchyma of rats treated with acetohydroxamic acid. Treatment with acetohydroxamic acid thus prevented invasion of and damage to kidney tissue without reduction of urinary infection. Thus new evidence was found that the invasive properties of Proteus in the urinary tract are dependent on alkalinization of urine by urease and the resulting damage to the renal epithelium.     

Urinary tract infections and chronic renal failure

The paper briefly summarizes issues related to urinary tract infections in adults: predispositions and risk factors, classification, assessment of pathogenicity of bacterial agents, the role of bacteriuria and leucocyturia, interpretation of findings, treatment principles and an association with chronic renal failure. Urinary tract infections are the second most frequent infectious disease in the population. They most often affect women of childbearing potential and then seniors of both sexes who have multiple risk factors. Escherichia coli and Staphylococcus saprophyticus are the most pathogenic towards urinary tract; they are responsible for 85% and 10-15% of cases of acute uncomplicated urinary infections, respectively. Chronic pyelonephritis, a chronic interstitial nephritis, is the fourth most frequent cause of chronic renal failure. Chronic renal failure is a risk factor for the development of urinary infections due to metabolic disorders resulting in secondary immunodeficiencywith a disorder of all components of immunity. In patients with chronic renal failure, urinary tract infections occur most frequently after kidney transplantation when graft pyelonephritis is a life-threatening complication. Therefore, urinary tract infection prevention with co-trimoxazole once daily over at least 6 months is recommended in renal allograft recipients.     

Ultrasonography and computed tomography in severe urinary tract infection

A prospective study evaluated the utility of renal computed tomography (CT) and ultrasonography in 35 patients hospitalized for treatment of urinary tract infection. Renal computed tomograms were abnormal in 18 of 28 patients with acute pyelonephritis and three of four patients with urosepsis, showing findings consistent with pyelonephritis in 17 patients and intrarenal abscess or focal bacterial nephritis in four patients. Renal sonograms were abnormal in only eight patients, showing findings compatible with pyelonephritis in four and intrarenal abscess or focal bacterial nephritis in the other four. Flank tenderness was absent in only four patients with CT findings of pyelonephritis, of whom three were diabetic. We therefore found that (1) renal CT is a sensitive test for acute upper urinary tract infection, (2) ultrasonography detects focal bacterial nephritis and abscesses but is insensitive to uncomplicated upper urinary tract infection, and (3) painless pyelonephritis may be more common in patients with diabetes mellitus.     

Treatment with a single daily dose of gentamicin in urinary tract infection in relation to the site of infection

Twenty-three patients with various types of recurrent urinary tract infection were treated with a single daily dose of 160 mg gentamicin for eight to nine days. The treatment eliminated bacteriuria in 19 patients. Evaluation of the therapeutical results according to the site of infection showed elimination of bacteriuria in all patients with lower urinary tract infection. Thus a single daily dose of gentamicin can be recommended in recurrent lower urinary tract infection, and also in upper urinary tract infection not associated with a major impairment of renal function.     

Single-dose treatment with netilmicin for different clinical forms of urinary tract infections

Summary A group of 44 patients with various clinical forms of urinary tract infections received a single dose of 300 mg netilmicin i.m. The treatment was efficacious in all patients with infections which were negative in the antibody-coated bacteria test and not complicated by anatomic and/or functional abnormalities of the kidneys and urinary tract. After three weeks the recurrence rate was only 19%. Single-dose treatment also proved very effective against urinary tract infections in renal transplant patients whose infection is almost always located in the lower urinary tract. In contrast, the short-term results of treatment were much poorer in complicated infections and particularly in urinary tract infections which were positive in the antibody-coated bacteria test; here, the recurrence rate was 67%.

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Therapie verschiedener klinischer Formen von Harnwegsinfektionen mit einer Einzeldosis von Netilmicin

Zusammenfassung 44 Patienten mit verschiedenen klinischen Formen von Harnwegsinfektionen wurden mit einer Einzeldosis von 300 mg Netilmicin i.m. behandelt. Die Therapie erwies sich als sehr wirksam gegen Infektionen bei allen Patienten mit negativen Ergebnissen im Test auf antikörperbeladene Bakterien und ohne anatomische und/oder funktionelle Nieren- und Harnwegsanomalien. Nach drei Wochen rezidivierte die Infektion nur bei 19% der Patienten. Nierentrans-plantierte patienten, bei denen die Infektion fast immer in den unteren Harnwegen lokalisiert ist, sprachen ebenfalls sehr gut auf die Behandlung mit einer Einmaldosis Netilmicin an. Die kurzfristigen Behandlungsergebnisse waren dagegen bei komplizierten Infektionen, insbesondere bei Harnwegsinfektionen mit positivem Test auf antikörperbeladene Bakterien, sehr viel schlechter; die Rezidivrate betrug 67%.