Abstract

Abstract

Seventy paired samples of urine, obtained by collection of a clean voided specimen and by suprapubic aspiration (SPA) of the bladder, were obtained from 43 male SCI patients who were free of indwelling catheters. The relationship of the presence or absence of symptoms and the degree of pyuria (determined quantitatively using a haemocytometer) to the presence or absence of bacteriuria (SPA specimen) was determined. Symptoms were poorly predictive of bacteriuria with concordance seen only 40% of the time. Most bacteriuric episodes (37/51–72.5%) were asymptomatic. The quantity of WBC in voided urine accurately reflected that in SPA urine (r = 0.825), indicating that urodynamics in SCI patients who received sphincterotomies are different than in normal persons. Pyuria (> 10⁴ WBC per cc urine) was an excellent predictor of UTI-37 of 38 (97.4%) had UTI. However, 40.6% of samples with WBC < 10⁴ were also culture positive. Overall, consideration of the presence or absence of pyuria in relation to the presence of bacteriuria provided a sensitivity of 74.0%, specificity of 95.9%, and predictive value of a positive test of 97.4%. The predictive value of a negative test (WBC < 10⁴), however, was only 59.4%. There was poor correlation between absolute bacterial and WBC count. The point of cutoff for bacterial count correlating with 10⁴ WBC count was not statistically significant in these patients; this is possibly due to repeated bacterial contamination from anterior urethra. While symptom status was often misleading, the presence of > 10⁴ WBC per cc of urine was highly predictive of the presence of bacteriuria in male SCI patients. As a reflection of inflammation, pyuria may further serve the purpose of distinguishing true bladder infection from simple colonization.     

Clinical studies of bacteriuria in renal transplantation recipients. Correlation with pyuria and symptomatic genitourinary tract infection

The clinical state of bacteriuria and its correlation with pyuria and symptomatic genitourinary tract infection (GUTI) were studied in 42 renal transplantation recipients who were followed up in the Kidney Center of Tokyo Women's Medical College over 6 months and who showed bacteriuria more than 3 times between January and December in 1987. The results were as follows. 1) Of the 42 recipients, bacteriuria was found less than 5 times in 19 patients, 6 to 10 times in 18 patients and more than 11 times in 5 patients. There was a tendency for the same bacteria to be isolated several times from the same patient. The most commonly isolated bacterias were Enterobacter, Enterococcus, Serratia and E. coli. 2) Bacteriuria was accompanied by pyuria in 33 patients (79%) and by symptomatic GUTI in 12 patients (29%). Bacteriuria without pyuria was shown in 9 patients (21%) without symptomatic GUTI and it was suggested that bacteriuria did not result in graft hypofunction after two years. 3) Of 16 patients with bacteriuria accompanied by pyuria, symptomatic GUTI occurred in 9 patients (56%). Of these, one patient was found to have VUR of the transplanted kidney, another was found to have VUR of the native kidney, and a third patient died due to interstitial pneumonitis presumably as a result of overimmunosuppression. Transplantation recipients with bacteriuria accompanied by pyuria develop symptomatic GUTIs frequently and should be treated with proper antibacterial agents. When bacteriuria continues, further examination should be performed for an organic disease of the urinary tract or an overimmunosuppressed state. When a patient shows bacteriuria without pyuria, chemotherapy is not needed and it is sufficient to observe the course carefully.     

Bacteriuria, pyuria and bacteremia frequency following outpatient cystoscopy

AIM: The assumed necessity of antimicrobial prophylaxis prior to cystoscopy is controversial. In this study, the rate of bacteriuria, pyuria and bacteremia in outpatients who underwent cystoscopy without antimicrobial prophylaxis is investigated prospectively. METHODS: The study included 75 patients who underwent cystoscopy for various indications and had sterile urine prior to intervention. A clean midstream urine sample was obtained 24 h before and 48 h after the procedure. Blood cultures were taken 1 h after cystoscopy. Patients were questioned for newly developed symptoms 48 h after cystoscopy. Blood cultures were taken again from patients who presented with fever. RESULTS: Six patients (8%) developed significant bacteriuria, and six patients (8%) developed pyuria without significant bacteriuria. Bacteremia was not determined in any of the patients. The association between presence of pyuria prior to the procedure and development of bacteriuria after the procedure was significant (P < 0.05). Four patients out of six who had bacteriuria were asymptomatic. In our study we found significant bacteriuria after cystoscopy in 8% of patients, and no bacteremia. CONCLUSIONS: Thus we conclude that cystoscopy is a safe and well-tolerated procedure. Antimicrobial prophylaxis should not be administrated unless specific indications are present.     

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.     

Prospective Randomized Comparative Study of Antibiotic Prophylaxis in Urethrocystoscopy and Urethrocystography

Background : There has been a great deal of discussion regarding the necessity of the prophylactic use of antibiotics in transurethral procedures. In order to clarify this complicated issue, a randomized prospective study was performed for patients undergoing urethrocystoscopy or urethrocystography.
Patients and Methods : Patients who underwent urethrocystoscopy or urethrocystography and did not have pyuria and bacteriuria were included and divided randomly into 2 groups, either receiving a prophylactic antibiotic or no antibiotic. For antibiotic prophylaxis, 200 mg of sparfloxacin or fleroxacin were administered within a 1-hour period before the urethrocystoscopic or urethrocystographic examination, respectively. Analyses were performed on patients who were seen within 1 month after the examination, using the appearance of pyuria, bacteriuria, or a febrile infection as the endpoint.
Results : Of47 patients undergoing urethrocystoscopy, 45 were eligible for analysis, and of these, sparfloxacin was administered to 21 patients. Thirty-three of 37 patients undergoing urethrocystography were eligible for analysis with fleroxacin administered to 16 patients. There were no significant differences in the background factors between the 2 groups undergoing either transurethral examination. None of the patients in either group developed pyuria, bacteriuria or a febrile infection after the examination.
Conclusions : Prophylactic administration of antibiotics is not necessarily essential in urethrocystoscopy or urethrocystography in patients with sterile urine.     

The analysis of prognostic factors on postsurgical pyuria of benign prostatic hypertrophy

The outcome of postsurgical pyuria in benign prostatic hypertrophy was studied in 87 patients, and the factors that might affect the outcome were determined. No significant differences were found between operation method and duration until normalization of pyuria, which was 75.5 +/- 46.0 days for transurethral resection of the prostate, 72.7 +/- 30.6 days for suprapubic prostatectomy and 69.3 +/- 32.7 days for retropubic prostatectomy. Prognostic factors were statistically analyzed preoperatively, at operation, and postoperatively. The definite prognostic factors were preoperative diabetes mellitus, preoperative pyuria, preoperative bacteriuria, and postoperative hypoproteinemia. The probable prognostic factors were old-age, preoperative indwelling catheters, heavy prostate tissue, postoperative bacteriuria, postoperative anemia and postoperative complications.     

Incidence of urinary tract infection following initiation of intermittent catheterization among patients with recent spinal cord injury in Germany and the Netherlands

Objective: To assess incidence of urinary tract infection (UTI) among patients with recent spinal cord injury (SCI) who initiated intermittent catheterization (IC).Design: Retrospective chart review.Setting: Two European SCI rehabilitation centers.Participants: Seventy-three consecutive patients with recent SCI who initiated IC.Outcome measures: Incidence of UTI, using six different definitions, each based on microbiology ± symptomatology ± mention of UTI . Rates were expressed in terms of numbers of UTIs per 100 patient-months (PMs). Attention was focused on first-noted UTI during the three-month follow-up, as assessed with each of the six definitions.Results: Fifty-eight percent of patients (n = 33) met ≥1 definitions for UTI during follow-up (rate: 31.5 UTIs per 100 PMs), ranging from 14% (5.3 per 100 PMs; definition requiring bacteriuria, pyuria, and presence of symptoms) to 45% (22.7 per 100 PMs; definition requiring “mention of UTI”). Ten cases were identified using the definition that required bacteriuria, pyuria, and symptoms, whereas definitions that required bacteriuria and either pyuria or symptoms resulted in the identification of 20–25 cases. Median time to UTI ranged from 42 days (“mention of UTI”) to 81 days (definition requiring bacteriuria and ≥100 leukocytes/mm³).Conclusion: Depending on definition, 14% to 45% of patients with recent SCI experience UTI within three months of initiating IC. Definitions requiring bacteriuria and either pyuria or symptoms consistently identified about twice as many cases as those that required all three conditions. Standardizing definitions may help improve detection, treatment, and prevention of UTI within this vulnerable population.     

Significance of immediate preoperative bacteriuria with pyuria in renal transplant recipients

The presence of bacteriuria and pyuria on urinalysis immediately before renal transplantation has resulted in cancellation of surgery because of concern about post-transplant wound infection. Of 113 renal transplant recipients reviewed 41 (36 per cent) had 5 or more white blood cells per high power field with bacteria in either a voided urine or bladder washout specimen obtained just before grafting. Of those 41 patients 2 suffered postoperative wound infections. Of 72 patients (64 per cent) with less than 5 white blood cells or no bacteria on a preoperative specimen 1 suffered a wound infection (p not significant by Fisher's exact test). Preoperative urine cultures and operative bladder cultures of all 3 patients failed to yield the organisms found later in the wound infections. The factors of sex, insulin-dependent diabetes, delayed graft function, living related versus cadaver donor and pre-transplant splenectomy had no significant relationship to wound infection rates. Renal transplantation can be performed safely in patients who have pyuria and bacteriuria but no signs or symptoms of infection.     

Encrustation and stone formation in double J ureteral stent: report of two cases

We recently experienced two cases of encrustation and stone formation on double J ureteral stent which had been indwelt at pyeloplasty and at pyelolithotomy. In these patients, bacteriuria and pyuria had continued. Encrustation and stone formation were recognized by follow-up X-ray fairly soon after operation. Judging from our experience, encrustation and stone formation should be suspected in patients with persistent bacteriuria and/or pyuria and who have episodes of urolithiasis. To avoid encrustation and stone formation, the ureteral stent should be replaced more frequently.     

Significance of bacteriuria in neurogenic bladder

OBJECTIVE: To investigate the usefulness of performing routine urine cultures in veterans with spinal cord injury (SCI) who come for annual evaluation. RESEARCH DESIGN/PARTICIPANTS: This retrospective study was performed on asymptomatic patients who came for outpatient annual evaluation. The records of 89 healthy male veterans with SCI between the ages of 22 and 82 years (mean age = 50.6) were reviewed from March through October 2000. METHODS: The following information was collected: patient's name, social security numbers, age, year of injury, level of injury, American Spinal Injury Association (ASIA) classification, urinalysis including white blood cell (WBC) count and presence or absence of nitrite, urine culture results (> or <100,000 colony-forming units of uropathogens per milliliter), blood WBC count, and mode of bladder management. The data were analyzed statistically to look at the effects of age at injury, level of injury, injury category (ASIA classification), pyuria, urinary nitrite, serum WBC count, and mode of bladder control on the presence of bacteriuria. RESULTS: Results revealed that regardless of the level of injury, individuals with ASIA A injuries were at high risk of having bacteriuria with positive culture results. Patients who were nitrite positive and/or had > or =6 WBCs per high-powered field (HPF) in the urine were also at high risk for significant bacteriuria. CONCLUSION: Urinary tract infections (UTIs) in the SCI population frequently are asymptomatic, polymicrobial, caused by antibiotic-resistant bacteria, and very likely to recur or relapse. However, there are no data to support or justify treatment of asymptomatic bacteriuria. The present study suggests that healthy asymptomatic patients with SCI who come for annual evaluations should not have routine urine cultures if they are at low risk for UTIs; that is, <6 WBC/HPF in the urine and/or nitrite negative.     

The course of pyuria after transurethral resection of the prostate and factor analysis of its duration

The course of pyuria and bacteriuria was reviewed in 54 patients undergoing transurethral resection of prostate. Pyuria, which was seen in all cases, lasted for 70.1 +/- 24.7 days and bacteriuria defined as more than 10(4)/ml occurred in 16 patients (30%) postoperatively. To analyze the factors affecting the duration of pyuria, we utilized Hayashi's multidimensional quantification I theory. The factors included age, serum protein, preoperative indwelling catheter, preoperative urinary tract infection, resected weight, postoperative infection, the duration of postoperative indwelling catheter, and the way of antibacterial prophylaxis. The most important factor was resected weight (range 42.8 days), the second was postoperative infection (range 23.9 days) and the third preoperative infection (range 20.9 days). The other factors had no significance. Our analysis showed good correlation between the observed and predicted duration of pyuria (r = 0.82, p less than 0.005).     

Screening for urinary tract infection using Bac-T-Screen bacteriuria device

The Bac-T-Screen was used to process 795 urine specimens. Tests for urine specimens took slightly more than two minutes. The Bac-T-Screen predicted with 99 per cent accuracy if a specimen was negative for bacteriuria or pyuria. Thus, approximately one half of all carefully collected urine specimens need no further laboratory culture. In addition, the Bac-T-Screen detected bacteriuria with a sensitivity of 96 per cent at the 10(5) CFU/ml level of probability. Pyuria (1 +) was detected with a sensitivity of 98 per cent. The Bac-T-Screen can be used in an office practice as well as in the clinical laboratory.     

Pyuria: index of infection in patients with spinal cord injuries.

Little is known about the significance of pyuria in patients with spinal cord injuries. The progress in hospital of 55 such patients was studied. They were divided into 2 groups according to the method of bladder drainage on admission. Group A comprised 43 patients with indwelling catheters. Group B comprised 12 patients who were able to void with tapping, with/without compression and on intermittent catheterisation. The results showed that group A had a mean pyuria level of 185 WBC/HPF on admission. The incidence of urinary tract infection was 4 per patient during hospitalisation and the mean duration of bladder training was 82 days. Group B had a mean pyuria level of 32 WBC/HPF on admission. The incidence of urinary tract infection was 1 per patient during hospitalisation and the mean duration of bladder training was 40 days. The difference between groups A and B for all 3 parameters was statistically significant. These results suggest that patients with spinal cord injuries and indwelling catheters have a higher pyuria level and an increased risk of significant morbidity secondary to urinary tract infection, especially at the pyuria level of 100 WBC/HPF. A low pyuria level of less than or equal to 30 WBC/HPF was associated with a nil or low incidence of bacteriuria and urinary tract infection in our patients.     

Quantitation of urinary Tamm-Horsfall protein in children with urinary tract infection.

It has been suggested that urinary Tamm-Horsfall protein (THP) prevents colonization of the urinary tract by binding uropathogens. We tested the hypothesis that low urinary THP levels may predispose to urinary tract infection (UTI) by measuring THP levels in children. We studied a cohort of 35 girls with uncomplicated recurrent UTI (group 1) that was compared with 27 patients with myelomeningoceles undergoing clean intermittent catheterization (group 2) and 16 female controls (group 3). We measured urinary THP in both aggregated (aTHP) and disaggregated form (dTHP), leukocyte esterase activity, urine chemistries and culture. No significant differences in dTHP or aTHP levels were seen between groups 1 and 3, but group-1 patients had higher dTHP levels than group-2 patients (p < 0.008). History of reflux or the presence of bacteriuria or pyuria at the time of urine collection did not affect dTHP levels; in contrast, pyuria or bacteriuria at the time of sampling was associated with markedly lower aTHP levels when compared with sterile samples (p < 0.0001). For all groups, measured quantities of dTHP did not correlate with aTHP levels. We conclude that excretion of dTHP in children with history of recurrent UTI is not reduced. In contrast, concentrations of aTHP are profoundly depressed in children during times of UTI, suggesting a role for THP in the pathogenesis of UTI. Assaying THP in its aggregated form may prove valuable when studying its physiologic function and merits further investigation.     

Elevated urinary cytokine levels in patients undergoing ileal neobladder replacement compared with sigmoid neobladder replacement

Objectives The objective of this study was to examine the urinary cytokine levels for assessment of inflammatory conditions in patients with orthotopic neobladder. Materials and methods Urinary levels of IL-1β, IL-6, and IL-8 were measured in 20 and 22 patients who underwent orthotopic neobladder replacement using ileum and sigmoid colon, respectively, and all cytokine levels greater than␣5 pg/ml were defined as elevated. The outcomes were compared with respect to several parameters. Results The proportions of patients positive for urinary culture, pyuria, and bacteriuria in the ileal neobladder group were higher than those in the sigmoid neobladder group, but these differences were not significant. Urinary levels of IL-1β, IL-6, and IL-8 in the ileal neobladder group were significantly greater than those in the sigmoid neobladder group. Furthermore, the incidences of elevated urinary levels of IL-1β, IL-6, and IL-8 in both groups were not affected by age, postoperative period, residual urine volume or pyuria; however, the incidences of elevated urinary IL-6 levels significantly differed between patients with and without bacteriuria in the ileal neobladder group, while there was a significant difference in the incidences of elevated urinary IL-8 levels between patients with and without bacteriuria in the sigmoid neobladder group. Conclusions These findings suggest that chronic inflammation was more frequently observed in patients with ileal neobladder than in those with sigmoid neobladder, and that IL-6 and IL-8 were involved in persistent bacteriuria in patients with ileal and sigmoid neobladder, respectively.     

Clinical studies on recurrence of acute uncomplicated cystitis

Recurrence rate and symptoms after chemotherapy against acute uncomplicated cystitis (AUC) were studied. Upon completion of a 7-day treatment with two regimens, one of CEX alone (Group C) and the other of a combination of CEX with Lysozyme (Neuzym) (Group L), at a dose of 1 g CEX daily, efficacy of the drugs was assessed according to the criteria established by the UTI Study Group. The forty one cases in Group C and 38 cases in Group L showing an excellent response were evaluated for recurrence. The rates of recurrence were 12.2% in Group C and 21.1% in Group L during the first 7 days after treatment. In recurrent cases, bacteriuria was seen in 84.6% (11/13), pyuria in 53.8% (7/13) and miction pain in 30.8% (4/13). Thus, bacteriuria and pyuria should be the items of the criteria for AUC recurrence.     

Present status on bladder replacement--colon bladder replacement]

Bladder replacement using a detubularized right colonic segment was successfully performed on 22 male patients with bladder cancer after radical cystectomy. There were 10 early postoperative complications and one of them required reoperation. Urodynamic studies, performed on 16 patients, showed a low pressure reservoir at a large capacity without any involuntary spikes in every case. Of the 16 patients, 4 were nocturnally enuretic and 1 was partially continent. The other 11 patients (68.8%) were totally continent and voiding well, except one who was on intermittent self-catheterization. The incidence of urinary reservoir infections in patients treated with colon bladder replacement was investigated in 18 patients. The incidence rate of bacteriuria was 5.6% and the positive rate of pyuria was 27.8%. The detection rate of bacteriuria and pyuria was significantly low in patients after colon bladder replacement. These findings indicate that colon bladder replacement can be an ideal option for selected patients with bladder cancer.     

Impact of urinary tract infection and detrusor pressure on renal tubular function in patients with vesicoureteral reflux

OBJECTIVE: The aim of this study was to evaluate prospectively the impact of bacteriuria with or without pyuria and/or detrusor pressure on renal tubular function in patients with secondary vesicoureteral reflux. METHODS: From October 1994 to December1998, we evaluated 54 patients with secondary vesicoureteral reflux (26 men and 28 women; age 30+/-24 years), of whom 28 had a neurogenic and 26 a nonneurogenic voiding dysfunction. In a reference population (n = 48; 28 men, 20 women; age 38+/-14 years), 43 had a neurogenic and 5 a nonneurogenic voiding dysfunction. Urinary alpha-1-microglobulin was measured immunonephelometrically. Statistical analysis was performed by multiple regression analysis. RESULTS: Patients with vesicoureteral reflux had a significantly higher urinary alpha-1-microglobulin/creatinine ratio. Urinary alpha-1-microglobulin excretion was related to the grade of vesicoureteral reflux, detrusor pressure and compliance, but not to bacteriuria or pyuria, and was diagnostic for vesicoureteral reflux with a sensitivity of 90%, a specificity of 70% and a negative predictive value of 97%. CONCLUSION: Urinary alpha-1-microglobulin excretion is diagnostically useful in patients with secondary vesicoureteral reflux. The use of urinary alpha-1-microglobulin excretion in the follow-up of patients with vesicoureteral reflux has yet to be established.     

Evaluation of 3 methods of bladder irrigation to treat bacteriuria in persons with neurogenic bladder

BACKGROUND/OBJECTIVE: We conducted a randomized, double-blind comparison of twice daily bladder irrigation using 1 of 3 different solutions in community-residing persons with neurogenic bladder who used indwelling catheters to evaluate efficacy in treatment of bacteriuria. METHODS: Eighty-nine persons with bacteriuria were randomized to irrigate their bladders twice daily for 8 weeks with 30 mL of (a) sterile saline, (b) acetic acid, or (c) neomycin-polymyxin solution. Urinalysis, cultures, and antimicrobial susceptibility tests were performed at baseline and weeks 2, 4, and 8 to determine the extent to which each of the solutions affected numbers and types of bacteria, urinary pH, urinary leukocytes, and generation of antimicrobial-resistant organisms. RESULTS: Bladder irrigation was well tolerated with the exception of 3 participants who had bladder spasms. None of the 3 irrigants had a detectable effect on the degree of bacteriuria or pyuria in 52 persons who completed the study protocol. A significant increase in urinary pH occurred in all 3 groups. No significant development of resistance to oral antimicrobials beyond what was observed at baseline was detected. CONCLUSIONS: Bladder irrigation was generally well tolerated for 8 weeks. No advantages were detected for neomycin-polymyxin or acetic acid over saline in terms of reducing the urinary bacterial load and inflammation. We cannot recommend bladder irrigation as a means of treatment for bacteriuria in persons with neurogenic bladder.     

Effect of cranberry extract on bacteriuria and pyuria in persons with neurogenic bladder secondary to spinal cord injury

OBJECTIVE: To determine whether antibacterial effects of cranberry extract will reduce or eliminate bacteriuria and pyuria in persons with spinal cord injury (SCI). DESIGN: Randomized, double-blind, placebo-controlled study. PARTICIPANTS: Participants were people with SCI residing in the community who were 1 year or longer postinjury with neurogenic bladder managed by intermittent catheterization or external collection device and a baseline urine culture demonstrating at least 10(5) colonies per milliliter of bacteria. METHODS: Each participant ingested 2 g of concentrated cranberry juice or placebo in capsule form daily for 6 months. Baseline urinalysis and cultures were performed at the time of the initial clinic visit and monthly for 6 months. Microbiologic data were evaluated using analysis of variance with repeated measures. RESULTS: Twenty-six persons received cranberry extract and 22 persons received placebo. There were no differences or trends detected between participants and controls with respect to number of urine specimens with bacterial counts of at least 10(4) colonies per milliliter, types and numbers of different bacterial species, numbers of urinary leukocytes, urinary pH, or episodes of symptomatic urinary tract infection. CONCLUSION: Cranberry extract taken in capsule form did not reduce bacteriuria and pyuria in persons with SCI and cannot be recommended as a means to treat these conditions.