Purple urine bag syndrome in a hemodialysis patient

Purple urine bag syndrome (PUBS) is an uncommon disorder, in which the plastic disposable urinary catheter bag turns purple or blue following hours or days of urinary catheterization. The purple discoloration results from indirubin dissolved in the plastic mixing with indigo in the urine. Bacteria possessing indoxyl sulfatase degrade indoxyl sulfate into indirubin and indigo. Indoxyl sulfate is derived from the metabolism of tryptophan. PUBS usually occurs in chronic catheterized elderly women who are constipated and poorly ambulant. The clinical course is benign and rarely causes sepsis. This investigation reports a 61-year-old female diabetic patient with end-stage renal disease on maintenance hemodialysis, who had two episodes of blue or purple urine bag discoloration. The urine culture of the first episode yielded Klebsiella pneumoniae, whereas that of the second episode yielded Escherichia coli, Enterococcus faecalis, and Proteus vulgaris. Both episodes resolved following oral antibiotics treatment and placement of new foley catheters. To our knowledge, this is the first recorded case of PUBS in a dialysis patient.     

Five cases of purple urine bag syndrome in a geriatric ward

We report five cases of purple urine bag syndrome (PUBS). All the patients were women and they had been bed-ridden for a long period due to cerebrovascular diseases. They tended to be constipated as a result of habitual use of laxatives. Indicanuria was proven in the all urinary samples from the patients. The four assessable urinary cultures showed Proteus mirabilis contamination. Total days without evacuation per month in patients with PUBS and control subjects (5 catheterized subjects without PUBS) were 16.5 +/- 3.7 and 6.8 +/- 4.8, respectively (mean +/- SD), showing a significant difference (p < 0.05). In each case, this syndrome was not considered to have affected their clinical course. We concluded that it is unnecessary to treat patients with PUBS aggressively. Control of evacuation and urological sanitation are important in these patients.     

Preventing catheter-related bacteriuria: should we? Can we? How?

Up to 25% of hospitalized patients undergo urinary catheterization, and about 5% develop bacteriuria each day of catheterization. Catheter-related bacteriuria is associated with increased morbidity and mortality. We performed an evidence-based synthesis of the literature on preventing catheter-associated urinary tract infections (UTIs) to develop recommendations for clinicians. Catheterization should be avoided when not required and when needed, should be terminated as soon as possible. Use of suprapubic and condom catheters may be associated with a lower risk of UTI than use of urethral catheters. Aseptic catheter insertion and a properly maintained closed drainage system are crucial to reducing the risk of bacteriuria. Instillation of antimicrobial agents into the bladder or urinary drainage bag and rigorous meatal cleansing seem to be of little benefit. Use of urinary catheters coated with silver alloy may reduce the risk of UTI. Systemic antimicrobial drug therapy seems to prevent UTIs, but primarily for patients catheterized for 3 to 14 days. Antibiotic drug prophylaxis is especially valuable in patients undergoing transurethral resection of the prostate or renal transplantation. Using these methods, urinary catheter-associated UTI can often be prevented for weeks, but not longer terms.     

Purple urine bag syndrome with acidic urine.

Purple discoloration of a urinary catheter bag is very rare. This phenomenon is known as the purple urine bag syndrome. It is associated with urinary tract infections occurring in catheterized patients, generally elderly females with significant co-morbidities and constipation. The urine is usually alkaline. We present a unique case of this rare and interesting phenomenon occurring in acidic urine and discuss the pathophysiology.     

Epidemiological and clinical aspects of urinary tract infection in community-dwelling elderly women

BackgroundUrinary tract infections (UTIs) in elderly patients can be a complex problem in terms of approach to diagnosis, treatment, and prevention, because the patients often present nonspecific symptoms. The epidemiological and clinical characteristics of UTI in elderly women were studied, in order to make early diagnosis and prevent serious clinical complications secondary to UTI.MethodsThis was a prospective population-based study, with elderly women, during their first medical office visit. Medical records were obtained by clinical history and physical examination in order to detect signs and symptoms of UTI and the presence of co-morbidities. Clean-catch midstream urine specimens for urinary dipstick test, sediment, and culture were collected; cervical samples for conventional Pap smears were also collected.ResultsUTI was found in 16.55% of elderly women. The most frequent urinary symptom was foul smelling urine, in 60.6%. E. coli was responsible for 98 (76.56%) cases of significant bacteriuria; 34 (34.69%) were resistant to trimethoprim-sulfamethoxazole, and 21 (21.42%) to fluoroquinolones. Asymptomatic bacteriuria (AB) was not treated. The presence of predisposing factors demonstrated that the history of previous UTI (p < 0.001), vaginitis (p < 0.001), and diabetes (p = 0.042) increased the risk for UTI.ConclusionThis study confirmed the high prevalence of UTI among elderly women and its unusual clinical presentation. Diabetes, history of previous UTI, and vaginitis were shown to be predisposing factors for UTI; it is not necessary to treat AB in elderly women, even among diabetics.     

Incidence of urinary tract infections in patients with short-term indwelling urethral catheters: a comparison between a 3-day urinary drainage bag change and no change regimens

BACKGROUND: The current practice of caring for hospitalized patients with indwelling urethral catheters in Siriraj Hospital is to change the drainage bag every 3 days. In an extensive medical literature search, no evidence was noted to support this practice. OBJECTIVE: The purpose of this study was to compare the incidence of catheter-associated urinary tract infections (UTI) in hospitalized patients with indwelling catheters who receive a drainage bag change every 3 days with the incidence of UTI in patients who receive no bag change. DESIGN: This study was a randomized controlled trial.Participants and study procedures: Of the patients at Siriraj Hospital, 153 with an indwelling urinary catheter for at least 3 days were randomized to a 3-day drainage bag change or a no change regimen. A urine sample was obtained from each patient for culture every 7 days, on the day the catheter was removed, or the day the patient was suspected of having a UTI. RESULTS: Of the 153 study patients, 79 were randomized to the 3-day bag change regimen, and 74 patients were in the no-change group. Both groups were comparable for all baseline characteristics. The incidence of symptomatic UTI was 13.9% in the 3-day drainage bag change group and 10.8% in the no change group (P =.7). The incidence of asymptomatic UTI was 36.7% in the 3-day bag change group and 36.5% in the no change group (P =.9). CONCLUSION: There is no evidence for the necessity of a bag change every 3 days at Siriraj Hospital; the urine bag can be left longer than 3 days. However, the appropriate frequency of urinary drainage bag change needs additional study because the sample size in this study does not rule out a false-negative result.     

Evaluation of urinary catheterization and urinary incontinence in a general nursing home population

The medical records of 412 residents of three southeastern Massachusetts nursing homes were reviewed to examine the frequency and medical management of urinary incontinence and the indications for chronic urinary catheterization. The mean age of the patients was 84.1 years. In this study 9.7% of the patients were managed with a urinary catheter, while an indication for catheterization was recorded in the medical records of only 27.5% of these patients. Half of the noncatheterized nursing home patients were transiently or permanently incontinent of urine, but were not catheterized. Incontinent patients without catheters were more likely to require assistance in toileting (75.5 v 26.1%) or to have bacteriuria (60.1 v 26.1%) than continent patients. Despite the frequency of urinary incontinence, this problem was included in the medical problem list of less than 5% of the incontinent nursing home patients. The authors conclude that urinary incontinence is a frequent medical problem in the nursing home population, but it is rarely recorded and evaluated as a medical problem. Furthermore, indications for urinary catheterization frequently are also not recorded. An explanation for this practice was not determined, but possibilities include a lack of physician knowledge of the evaluation and management of incontinence and a nonaggressive approach to such patients, given their other medical problems.     

UTI: managing the most common nursing home infection

Urinary tract infections (UTIs) are the most common type of infection in nursing homes. Asymptomatic bacteriuria, the most common form, requires no treatment. Symptomatic UTI requires treatment, but symptoms (acute deterioration in functional ability or mental status) may be nonspecific. Complicated UTI is more common in nursing home residents than in other populations. Immobility and the use of bedpans instead of commodes contribute to decreased bladder emptying and an increased potential for UTI. Poor perineal hygiene in many females in nursing homes also increases the potential for UTI. For this reason, obtaining urine for culture by catheterization rather than voided specimen should be the norm for female nursing home patients.     

Role of biofilm in catheter-associated urinary tract infection

The predominant form of life for the majority of microorganisms in any hydrated biologic system is a cooperative community termed a "biofilm." A biofilm on an indwelling urinary catheter consists of adherent microorganisms, their extracellular products, and host components deposited on the catheter. The biofilm mode of life conveys a survival advantage to the microorganisms associated with it and, thus, biofilm on urinary catheters results in persistent infections that are resistant to antimicrobial therapy. Because chronic catheterization leads almost inevitably to bacteriuria, routine treatment of asymptomatic bacteriuria in persons who are catheterized is not recommended. When symptoms of a urinary tract infection develop in a person who is catheterized, changing the catheter before collecting urine improves the accuracy of urine culture results. Changing the catheter may also improve the response to antibiotic therapy by removing the biofilm that probably contains the infecting organisms and that can serve as a nidus for reinfection. Currently, no proven effective strategies exist for prevention of catheter-associated urinary tract infection in persons who are chronically catheterized.     

The problem of bacteriuria with indwelling urethral catheterization

Bacteriuria following long-term catheterization is more likely to occur in elderly females over the age of 50 years, in patients with some abnormality of the bladder and when traumatic catheterization has taken place. Breaks in the closed system of drainage are the most important factors leading to bladder infections which, once there, are difficult to eradicate. Antiseptics are important at the time of catheterization but have little place afterwards except to reduce cross-infection and growth in the catheter bag. Systemic antimicrobials are only of use over a short period of catheterization and should be reserved in long-term catheterized patients for those with systemic manifestations of infection.     

Is routine screening for urinary tract infection in rehabilitation day-hospital elderly patients necessary?

It is not known whether all rehabilitation day-hospital patients need to be assessed for urinary tract infection (UTI). The aims of this study were to identify patients at high risk to develop UTI and to determine whether there was an association between the amount of post-void residual urine (PVR) and UTI. We surveyed 211 consecutive patients admitted to the day-hospital unit of a geriatric rehabilitation center between June 1998 and February 1999. The main diagnoses were stroke, orthopedic surgeries and deconditioning. Urine samples for general analysis and bacteriology were collected from each patient upon admission. PVR was measured using portable ultrasound. Telephone interviews were conducted with 141 patients, 3-11 months after the initial screening. The prevalence of UTI at admission was higher in women (P=0.007), and patients with decreased functional level (P=0.001). The incidence rate correlated with the functional level but not with gender or main diagnosis. The relative risk of dependent patients to develop UTI was 7.5 times higher than in independent patients. Significant amounts of PVR were equal in males and females. The relative risk of individuals with significant amounts of PVR to develop UTI was 1.63 times greater then those with negligible and moderate amounts of PVR. Gender, degree of functional level and main diagnosis had no effect on the relationship between PVR and UTI. We conclude that low functional level and significant amounts of PVR are risk factors for prevalence and incidence of UTI in elderly patients in a rehabilitation day-hospital. There is no need for routine urine analysis in every elderly patient admitted to rehabilitation day-hospitals, however, PVR measurements by portable ultrasound are valuable.     

Factors contributing to susceptibility of postmenopausal women to recurrent urinary tract infections.

Recurrent urinary tract infections (UTIs) account for substantial morbidity, losses in work time, and medical costs. Recent studies suggest that the major factors predisposing to recurrent UTIs differ by age and functional status. In premenopausal women, sexual intercourse, spermicide exposure, maternal history of UTI, and a history of UTI in childhood have been associated with recurrent infections. In postmenopausal women, lack of estrogen appears to be an important factor predisposing to recurrent UTI, as does nonsecretor status, a history of UTI in the premenopausal period, incontinence, presence of a cystocele, and postvoid residual urine. In older women who are institutionalized, catheterization, incontinence, antimicrobial exposure, and functional status are most strongly related to risk of recurrent UTI. Further research is needed to better identify measures for prevention of recurrent UTI, which likely differ by age group.     

Analysis of urinary tract infections in hospitalized elderly patients, with particular reference to the use of diapers]

We investigated the clinical and laboratory data of 215 hospitalized patients (mean age were 76.9 +/- 12.1) to analyze both the characteristics of senile UTI and the influence of the way of urination. UTI was present in 121 of 1897 patients (6.4%), 95 of whom (78.5%) were female. Comparison of the parameters between non-infected and infected patients were as follows: body temperature was 36.57 +/- 0.64 degrees C vs. 37.49 +/- 0.77 degree C; WBC, 5410 +/- 2040/microliters vs. 7260 +/- 3230/microliters; CRP, 1.2 +/- 2.4 mg/dl vs. 3.5 +/- 3.4 mg/dl; mean class of urinary RBC, 0-1/hpf vs. 3-5/hpf; and mean class of urinary WBC, 5-10/hpf vs. 30-50/hpf. All parameters were significantly elevated (p < 0.001) in the patients with UTI. The rate of detection of causative bacteria was 88.7%; with 14.8% Escherichia coli, 12.8% Providencia species, 9.6% Enterococci, and 8.7% Pseudomonas aeruginosa. Patients with UTI were divided into three groups according to their method of urination: normal urination, use of diapers and catheterization. Body temperature (> or = 37.5 degrees C) was 2.8%, 10.1% and 34.9%; WBC (> or = 9.000), 2.7%, 6.1%, and 14.3%; CRP, 16.9%, 36.1% and 51.1%; urine RBC (> or = 6-10/hpf), 8.4%, 7.1% and 36.1%; urine WBC (> or = 15-30/hpf), 20.4%, 44.4% and 76.9%, respectively. There was a significant difference (p < 0.05-0.001) between all parameters except for urine RBC between the normal-urination patients and diaper using patients. This investigation suggested that the use of diapers was a risk factor for UTI in elderly patients.     

Urinary tract infections

Catheter-associated urinary tract infections (CAUTIs) account for approximately 40% of all health care-associated infections. Despite studies showing benefit of interventions for prevention of CAUTI, adoption of these practices has not occurred in many healthcare facilities in the United States. As urinary catheters account for the majority of healthcare-associated UTIs, the most important interventions are directed at avoiding placement of urinary catheters and promoting early removal when appropriate. Alternatives to indwelling catheters such as intermittent catheterization and condom catheters should be considered. If indwelling catheterization is appropriate, proper aseptic practices for catheter insertion and maintenance and use of a closed catheter collection system are essential for preventing CAUTI. The use of antimicrobial catheters also may be considered when the rates of CAUTI remain persistently high despite adherence to other evidence-based practices, or in patients deemed to be at high risk for CAUTI or its complications. Attention toward prevention of CAUTI will likely increase as Center for Medicare and Medicaid Services and other third-party payers no longer reimburse for hospital-acquired UTI.     

Catheter associated urinary tract infections in neurology and neurosurgical units

OBJECTIVE: Catheter associated bacteriuria is the most common infection acquired in hospitals. The objective of the study was (1) to study the incidence of bacteriuria following indwelling urethral catheterization in patients with short-term vs long-term catheterization (2) to define the antibiotic resistance pattern among these isolates so that the study can provide guidelines for choosing an effective antibiotic against infections in catheterized patients. METHODS: This is a prospective study carried out over a period of 18 months in Neurology/Neurosurgical patients who had indwelling catheters for > or =48 h. RESULTS: In this study, 68 out of 800 (8.5%) adult inpatients acquired urinary tract infection following indwelling bladder catheterizations. The risk was significantly higher for female, elderly patients, critically ill and patients on prolonged catheterization. Among the bacterial pathogens, Escherichia coli was the commonest organism isolated (32.9%) followed by Pseudomonas sp. (15.1%) and Staphylococcus aureus (12.3%). Candida sp. comprised 13.7% of all isolates. Among Gram negative bacterial pathogens maximum number of isolates were sensitive to Amikacin (sensitivity of 42%). All Gram positive organisms were however sensitive to Vancomycin. CONCLUSIONS: Our results provide guidelines for choosing salvage therapy against hospital resistant strains causing infection in catheterized patients. However, antibiotics seem to prevent urinary tract infections but primarily in patients catherized for short duration, i.e. 3-14 days and not in patients with long-term catheterization.     

The effect of urinary bladder catheterization on patient care in an internal medicine department

IntroductionRecommendations for urinary catheterization in newly hospitalized patients are inconsistent and unclear.MethodsThe authors studied prospectively consecutive patients who were catheterized in an internal medicine department over a 3-month period, with follow-up for 6 months or until the catheter was removed. Patient records were reviewed to determine if catheterization was definitely not indicated by commonly accepted criteria. After chart review, a category of possibly not indicated was defined as having no demonstrable effect on patient care.ResultsThere were 17.7% patients (122/691) catheterized during their admission. According to accepted criteria, definite inappropriate catheterization occurred in 18 patients (14.7%). There were an additional 69 patients (56.6%) with unclear clinical benefits, hospitalized because of fever, acute congestive heart failure, a cerebral vascular accident or respiratory insufficiency due to exacerbation of chronic obstructive lung disease. During hospitalization, attempts to remove the catheter failed in 13 patients, 4 of who remained with the catheter permanently, complicated by urosepsis in 1 patient.ConclusionOver 50% of the patients had acceptable indications for catheterization but no demonstrable benefit from the procedure. In such patients, the uncertain benefits of catheterization should be balanced by potential complications. Additional studies are warranted to determine the effect of acute urinary catheterization on patient care.     

Présentation clinique et performance de la bandelette urinaire pour le diagnostic d’infection urinaire en population gériatrique

BackgroundUrinary tract infections (UTI) are the second cause of community-acquired bacterial infections in the elderly. Distinguishing symptomatic UTI from asymptomatic bacteriuria is problematic, as older adults are less likely to present with localized urinary symptoms. We evaluated characteristics of patients presenting UTI among elderly with sepsis. Moreover, we aimed to evaluate the sensibility and specificity of urine dipstick tests in the diagnosis of UTI in geriatric population.Patients and methodWe led a prospective, monocentric, observational study between April 2017 and January 2018. We included patients hospitalized in geriatric wards, who were prescribed urine culture for UTI symptoms or/and infection without primary sites for which a urine culture was prescribed. Dipstick urinalyses were performed for all patients.Clinical and biological characteristics of all patients were compared according to the final diagnosis of UTI. Moreover, results of dipstick tests were evaluated for the diagnosis of UTI in this population.ResultsAmong 165 patients, 67 (40.6 %) had a UTI and 98 (59.4 %) had another diagnosis. These two groups were comparable for age and daily-living activities. In the UTI group, the proportion of women was higher than in the other group (P < 0.05), and mean MMSE score was lower (P < 0.05).Positive urine dipstick test for leukocytes and/or nitrites had high sensitivity (92 %), but low specificity (50 %). Negative predictive value of this test was high (91 %).ConclusionFor suspicion of UTI among elderly, few criteria are specific. Negative dipstick tests can suggest an absence of UTI due to its high negative predictive value.     

Reducing urinary tract infections in catheterized patients

To compare the effectiveness of two drainage systems in controlling urinary tract infections (UTIs), 65 elderly home care patients with indwelling urinary catheters participated in a retrospective intervention study. The patients first used a Foley drainable bag (DB) system, followed by a nondrainable one (NDB). Both systems used a Foley catheter. Data were obtained from physicians, nurses, caregivers, and patients regarding the number of UTIs and hospitalizations that occurred when using each system. Using the DB, 65 patients had 1,395 UTIs, 27 of which required hospitalization. Using the NDB, 2 patients had 71 UTIs, 2 of which required hospitalization. The cost for the non-hospitalization UTIs with DBs was estimated at $1,153,665 compared to $57,890 with NDBs. The hospital costs with DBs were estimated at $274,170 and $15,540 with NDBs. Because DBs were used longer than NDBs (mean = 44.4 months and 8.8 months, respectively), patients who used each bag for the same period of time were compared. When these patients used NDBs they had significantly fewer UTIs (56, with one hospitalization for 7 days) than when they used DBs (242, with 10 hospitalizations for 37 days). Although the cost of purchasing the non-replaceable NDBs is greater, the use of NDBs drastically reduced levels of infection as well as the overall cost to maintain catheterized patients.     

A clinical study on patients with urinary tract infection due to coagulase-negative staphylococci.

To assess the clinical significance of coagulase-negative staphylococci (CNS) in patients with urinary tract infection (UTI), the clinical characteristics of a total of 117 patients (106 complicated UTI patients, 11 uncomplicated UTI patients) from whom CNS were isolated at urinary colony counts of 10(5) or more per ml were studied. Of the complicated UTI patients, 95 patients (89.6%) suffered from no symptoms while 11 (10.4%) had fever of 38 degrees C or greater, which was strongly suspected to be due to genitourinary tract infections. Six of these patients were managed by indwelling urinary catheters. On the other hand, all of the patients with uncomplicated UTI were young women and had typical symptoms of acute cystitis. These results suggest that CNS, which hitherto have been considered mere contaminants or benign colonization rather than true pathogens, can also cause complicated UTI requiring chemotherapy under certain conditions such as indwelling urinary catheterization and acute cystitis in sexually active women.     

Profile and prognosis of febrile elderly patients with bacteremic urinary tract infection

OBJECTIVE: To describe the profile of elderly patients with bacteremic urinary tract infections (UTI) and correlate clinical and laboratory findings with the outcome in order to identify independent predictors of mortality. METHODS: This retrospective study took place in a large community-based, geriatric hospital and included 191 patients aged 75-105 years with urine and blood cultures simultaneously positive for bacterial organisms. Records were analysed for demographic information, clinical and laboratory data over a 29 month period. Mortality was assessed and was correlated with these findings. RESULTS: Most of the patients (80.1%) had community-acquired infection. Gram-negative organisms accounted for 87.6% of bacterial isolates, with Escherichia coli accounting for 46.1% of cases. Non-Escherichia coli Gram-negative organisms were highly resistant to two common urinary tract antibiotics (gentamicin and ceftriaxone). Patients with chronic urinary catheter had Gram-negative bacteria significantly less sensitive to ciprofloxacin, gentamycin, ampicillin and ceftriaxon than patients without catheter (p<0.05). In-hospital mortality was 33%. Multiple logistic regression analysis revealed that mortality was significantly related to the number of underlying diagnoses (p<0.0203), cognitive status (p<0.0003), length of hospitalization (p<0.0397), low level of serum albumin (p<0.0021), high neutrophil count (p<0.0001) and high level of lactate dehydrogenase (p<0.0351). Fatality was not associated with advanced age in the very old. CONCLUSION: Bacteremic UTI in the elderly has a high mortality rate. In frail elderly patients with age-associated multiple severe underlying disorders and cognitive impairment, early recognition of bacteremic UTI and prompt, appropriate treatment are critical in reducing the mortality.