Prevention and treatment of complicated urinary tract infection

A complicated urinary tract infection (UTI) has relapsing and refractory characteristics, and is sometimes life-threatening because of patient predisposing factors as well as the recent worldwide spread of multi-drug resistant bacteria. Patients with complicated UTI should be treated with effective antimicrobial therapy along with appropriate urological intervention to remove predisposing factors when the symptoms are associated. By contrast, routine use of antimicrobial prophylaxis for asymptomatic bacteriuria (ASB) is not recommended, as that would contribute to an increase in even more resistant pathogens. Here, four classifications of complicated UTI, which are considered to be clinically important for general urologists, are reviewed, including UTI in patients with diabetes mellitus (DM) and those with a neurogenic bladder, as well as catheter-associated UTI (CAUTI) and obstructive pyelonephritis secondary to urolithiasis. Appropriate treatment approaches can only be chosen by proper understanding of the etiologies of complicated UTI, as well as correct diagnostic strategies and treatment options.     

Validation of a patient-administered questionnaire to measure the severity and bothersomeness of lower urinary tract symptoms in uncomplicated urinary tract infection (UTI): the UTI Symptom Assessment questionnaire

OBJECTIVE: To develop and validate a self-administered questionnaire to assess the 'severity' and 'bothersomeness' of the most frequently reported signs and symptoms of uncomplicated urinary tract infection (uUTI). SUBJECTS AND METHODS: The UTI Symptoms Assessment questionnaire (UTISA) is a 14-item instrument asking about the severity and bothersomeness of seven key uUTI symptoms. It was developed after comprehensive literature and data review and administration in draft form to a sample of 30 women with uUTI. The final questionnaire was completed by 276 women with uUTI who participated in a noncomparative clinical trial of ciprofloxacin. The women completed the questionnaire in electronic format at baseline (before the first dose of ciprofloxacin once-daily), at 3-h and 8-h intervals until all UTI symptoms were resolved, and at the test-of-cure visit. Baseline scores on the King's Health Questionnaire (KHQ) were used to assess convergent and divergent validity; responses to the Global Rating of Change (GRC) were used to assess both responsiveness and the 'minimally important difference'. Discriminant validity and responsiveness were assessed by comparing UTISA scores with a clinical evaluation of UTI symptoms performed by the investigator at baseline and at the test-of-cure visit. RESULTS: The UTISA was found to comprise three four-item domains named 'urination regularity', 'problems with urination', and 'pain associated with UTI'. Two questions asking about haematuria loaded on a fourth factor. The three domains were homogeneous (with high inter-item correlations) and internally consistent. Convergent validity was shown by high correlations between similar UTISA and KHQ domains (all r(s) > 0.40), and divergent validity by small correlations between unlike domains (all r(s) < 0.15). In general, the UTISA domains showed excellent discriminant validity, with scores on selected domains discriminating between women with different clinical evaluations. The responsiveness of the UTISA was also excellent, with high correlations between changes in domain scores and the clinical evaluation and GRC items. Symptom improvement was highest in the first 3 h, leading to greater responsiveness and minimally important difference during this period. However, the UTISA could detect even small subsequent changes. CONCLUSION: The three-domain UTISA has excellent psychometric properties and it is likely to prove an excellent tool for assessing uUTI outcome from a patient's perspective, both in research and clinical settings.     

Efficacy and safety of tigecycline for complicated urinary tract infection: a systematic review

BackgroundFacing the global threat of emerging resistance to antibiotics, tigecycline, a novel glycylcycline antibiotic, is developed to against multidrug-resistant pathogens, but not recommended for the treatment of complicated urinary tract infection (cUTI). We performed a summary of the literatures to characterize and evaluate the efficacy and safety of tigecycline in patients with cUTI.MethodsWe searched PubMed, EMBASE, Cochrane and Clinical Trials using appropriate syntax to retrieve potential articles up to Jan 2020. General information, pathogen, medication regimen, comorbidities of patients from eligible literatures were recorded. Univariate logistic regression analysis was used to detect the potential factors associated with clinical cure.ResultsNineteen articles comprising 31 cases were included. The subpopulation with transplantation (25.8% of the patients) was the most common comorbidity, and cUTIs were mainly caused by Klebsiella pneumoniae (K. pneumoniae) (48.28%) in our research. Tigecycline 100 mg per day as monotherapy was most common. Clinical cure was reported as majority (77.4%), and microbiological eradication cases accounted for the most (65.2%) among the clinical cure cases. Univariate analysis showed that K. pneumoniae caused cUTI and tigecycline as a single treatment have significant meaning to clinical outcomes (P=0.044 and P=0.034, respectively).ConclusionsClinical and microbiological outcomes of tigecycline treatment revealed high rate of successful response. Tigecycline monotherapy may have a role in the treatment of cUTI except that caused by the pathogen K. pneumoniae. Further randomized controlled trials was still needed to evaluate tigecycline monotherapy for cUTI.     

Primary urinary tract infection in infants: prophylaxis for uncomplicated pyelonephritis

BACKGROUND: Urinary tract infection (UTI) is one of the most common causes of unexplained fever in infants with a reported prevalence range of 5-11%. The clinical and laboratory findings were reviewed, and diagnosis and treatment for 95 infants with primary UTI were evaluated in this study. METHODS: All patients underwent renal ultrasonography, voiding cystourethrogram and 99mTc dimercaptosuccinic acid (DMSA) scan during hospitalization before treatment, with treatment consisting of 2- or 4-week appropriated antibiotic therapy for the patients associated upper UTI, followed by a second DMSA scan 6 months after therapy. RESULTS: In the present study the main symptom of UTI in infants was fever. High white blood cell count was not necessarily present, and urinalysis was also an imperfect diagnostic tool for discriminating UTI. In addition, colony count from urine culture and kidney ultrasonography was not efficacious in terms of predicting the occurrence of pyelonephritis. Intravenous antibiotic for 1 week followed by 3 weeks of the same oral antibiotic provided good prophylaxis for uncomplicated pyelonephritis. CONCLUSION: Four weeks of antibiotic treatment resulted in good recovery from pyelonephritis in the present sample of infant primary UTI cases. voiding cystourethrogram, DMSA and ultrasonography scanning should be performed in primary infant UTI.     

Complicated urinary tract infection caused by Pseudomonas aeruginosa in a single institution (1999–2003)

BACKGROUND: Pseudomonas aeruginosa has been an important uropathogen that causes complicated urinary tract infection. We investigated the clinical characteristics of complicated urinary tract infection caused by Pseudomonas aeruginosa in a single institution. METHODS: We studied those patients who had basal disease in their urinary tract that was diagnosed as urinary tract infection caused by more than 10(4) colony forming units (CFU)/mL of Pseudomonas aeruginosa isolated from their urine. In those patients, we analysed infectious risk factors, treatment methods including the use of antimicrobial agents, the presence of a urinary tract catheter, and the relationship between febrile infection and urinary tract catheter. In addition, we examined the various antimicrobial susceptibilities against Pseudomonas aeruginosa. RESULTS: We studied 76 patients (59 men and 17 women). Of their basal diseases of the urinary tract, bladder tumor was the most prevalent (42.1%). Of the 39 patients who had an indwelling urinary tract catheter, 26 (66.7%) experienced a high-grade fever, a higher rate than that of the 37 patients who were not catheterized (40.5%). Seven patients were treated with anticancer chemotherapy drugs and 31 cases of urinary tract infection caused by Pseudomonas aeruginosa were diagnosed in the perioperative period. Piperacillin showed lower susceptibility against Pseudomonas aeruginosa in these 2 years (P<0.05). CONCLUSIONS: Our results indicated that those patients with urinary tract catheterization had a higher incidence of fever than patients without catheterization. Therefore, we must improve not only the antimicrobial treatment of Pseudomonas aeruginosa but also our management of catheters.     

Rapid detection of urinary tract pathogens using microcalorimetry: principle, technique and first results

Study Type – Diagnostic (exploratory cohort) Level of Evidence 2b What's known on the subject? and What does the study add? Microcalorimetry has been applied in several microbiological studies, but never in a clinical urological context. In addition, basic knowledge on the growth of urinary pathogens in urine is still scarce and data regarding the growth rate of many urinary pathogens in urine are still not available. The study demonstrates that this innovative application of microcalorimetry is useful in (i) investigating the growth of urinary pathogens in sterilized urine and (ii) as a rapid tool for diagnosis of urinary infection as well as for further identification of the causative infectious agent.

OBJECTIVE

• ? To investigate the value of isothermal microcalorimetry (IMC) in the detection and differentiation of common urinary tract pathogens in urine. IMC is a non‐specific analytical tool for the measurement of heat in the microwatt range.

PATIENTS AND METHODS

• ? A microcalorimeter equipped with 48 channels was used. Detection was accomplished, and growth was monitored for four bacterial strains in sterilized urine at 37 °C by measuring metabolic heat flow (µW =µJ/s) as a function of time.
• ? The strains were Escherichia coli, Proteus mirabilis, Enterococcus faecalis and Staphylococcus aureus.

RESULTS

• ? Bacterial growth was detected after 3.1 to 17.1 h with decreasing inocula.
• ? The detection limit was 1 colony‐forming unit (CFU)/mL for E. coli, 10 CFU/mL for P. mirabilis and E. faecalis and 10³ CFU/mL for S. aureus.
• ? The total heat was highest in P. mirabilis ranging from 10 to 12 J, followed by E. coli (3–4 J), S. aureus (2–3 J) and E. faecalis (1.3–1.5 J).
• ? The shape of the heat flow curves was characteristic for each species independent of its initial concentration.

CONCLUSIONS

• ? IMC allows rapid detection of bacteriuria, much faster than conventional culture. Urinary tract pathogen detection after only 3.1 h is realistic.
• ? Clearly different heat flow patterns enable accurate pathogen differentiation.
• ? Due to expeditious identification of urine samples that contain only low colony counts (i.e. less than 10³ CFU/mL), IMC may become a valuable screening tool for detecting the presence of significant bacteriuria.

     

A modified Whitaker test (upper urinary tract videourodynamics) using for evaluating complex upper urinary tract reconstruction surgical effect

BackgroundTo evaluate the feasibility and effect of upper urinary tract videourodynamics in complex reconstructed upper urinary tract.MethodsFrom January 2016 to December 2018, patients who underwent complex upper urinary tract reconstruction and received upper urinary tract videourodynamics were included in the study. The modified Whitaker test was performed at 3 months after operation. The relative pelvic pressure was defined as the pelvic pressure minus the bladder pressure. Based on the flow rate, the test was divided into physiological phase and high flow phase. The results of pressure and image were classified into 3 types. Successful nephrostomy removal was defined as no symptoms and improved or stable hydronephrosis.ResultsA total of 12 patients who underwent complex upper urinary tract reconstruction received modified Whitaker test. All tests were successfully completed without adverse reactions. The relative pelvic pressure of 3 patients kept steady near the baseline throughout the examination and was classified into type 1. The pelvic pressure of 7 patients increased as the perfusion continued, and the relative pressure dropped to relative low level due to the peristalsis of ureter (type 2). The pressure of 2 patients increased along with increasing perfusion speed, and the relative pelvis pressure could easily reach 15 cmH2O. The peristalsis of ureter disappeared or appeared very weakly on the video record (type 3). Patients in type 1 (3 cases) and type 2 (7 cases) groups were allowed to remove the nephrostomy tube immediately. Patients in type 3 group needed to keep the nephrostomy for close follow up, and the tubes were removed 2 weeks and 4 weeks after the examination, respectively. None of the 12 patients received further treatment for recurrent symptoms and exacerbation of hydronephrosis.ConclusionsThe modified Whitaker test is initially safe and feasible in postoperative evaluation of complex upper urinary tract reconstruction surgery. Detailed results can provide more evidence to judge whether nephrostomy tube could be removed safely.     

Management of phimosis as a risk factor of urinary tract infection: An Asian perspective

Many studies have been published to examine whether circumcision has any advantageous effect on the prevention of urinary tract infection (UTI), especially in male infants with vesicoureteral reflux (VUR). Colonization of bacteria in the inner prepuce and its reduction by circumcision has been documented, and circumcision may reduce the risk of febrile UTI (fUTI) in males. Circumcision is described as a therapeutic choice against VUR in the current American Urological Association and European Association of Urology/European Society for Pediatric Urology guidelines. In countries where neonatal circumcision is routinely performed, there may exist no clinical problems with regard to this issue. However, in Asian countries, there is a sharp division in the prevalence of circumcised males; for example, it is > 80% in Islamic countries, South Korea, and the Philippines, but its prevalence is < 20% in the majority of the other countries, including China, India, Japan, and Taiwan. In countries where neonatal circumcision is routinely performed, no clinical problem exists with regard to using it as a treatment for VUR. By contrast, in countries where circumcision is not routinely performed for children, strong objection exists against using this procedure for this purpose. Thus, treatment for fUTI among uncircumcised boys in these countries should be further studied in a separate context from the countries where circumcision is highly prevalent. In countries such as Korea and the Philippines where circumcision is performed during childhood, but not as a routine procedure in neonates, one may have an obligation to present circumcision as a choice of treatment for male infants with fUTI and/or VUR, and setting an appropriate age for circumcision could be an important clinical question.     

A pilot randomized double-blind placebo-controlled trial on the use of antibiotics on urinary catheter removal to reduce the rate of urinary tract infection: the pitfalls of ciprofloxacin

OBJECTIVE: To assess if a short course of antibiotics starting at the time of the removing a short-term urethral catheter decreases the incidence of subsequent urinary tract infection (UTI). PATIENTS AND METHODS: Patients across specialities with a urethral catheter in situ for >/= 48 h and 相似文献   

Core lower urinary tract symptom score (CLSS) for the assessment of female lower urinary tract symptoms: a comparative study

Objective: We have recently developed the core lower urinary tract symptom score (CLSS) questionnaire to readily address 10 important lower urinary tract symptoms (LUTS). The aim of the present study was to evaluate the performance of the CLSS in women compared with the International Prostate Symptom Score (IPSS) and Overactive Bladder Symptom Score (OABSS). Methods: Three hundred and eighteen treatment‐naïve consecutive female patients, including 48 controls, completed the three questionnaires. Quality of life (QOL) was determined as per the IPSS QOL Index. The clinical diagnoses were overactive bladder (n = 69), mixed incontinence (n = 42), stress incontinence (n = 17), pelvic organ prolapse (n = 56), interstitial cystitis (n = 31), bacterial cystitis (n = 16), underactive bladder (n = 16), and “other” (n = 23). Simple statistics and the relationship between symptom scores and poor QOL (QOL Index ≥4) were examined. Results: All symptom scores were significantly increased in symptomatic women. The CLSS described the symptom profiles of patients with distinct conditions. The scores of corresponding symptoms on the three questionnaires were significantly correlated (r = 0.51–0.85; all P < 0.0001). Multivariate logistic regression modeling proved five CLSS symptoms (daytime frequency, nocturia, urgency incontinence, straining, and urethral pain) as independent predictors of poor QOL, with hazard ratios ranging from 2.0 to 4.2. The IPSS included only two (urgency and straining) significant symptoms. Conclusions: The IPSS alone does not fully evaluate female LUTS, with a possible negative impact on QOL. Using the CLSS questionnaire would enable a simple and comprehensive assessment of female LUTS.     

Clinical evaluation of cefmenoxime (CMX) for complicated urinary tract infection

Cefmenoxime (CMX), a new semisynthetic antibiotic, was administrated in 29 cases diagnosed as complicated urinary tract infection. All patients received drip injection of 2 g (twice a day) for 5 days. Clinical results were excellent in 1 patient (3.4%), good in 15 patients (51.8%) and poor in 13 patients (44.8%). Effectiveness rate was 55.2%. In bacteriological response, out of 35 strains 27 (77.1%) strains were eradicated and 8 (22.9%) strains persisted. As for side effects, except one case of transient diarrhea after administration, no noteworthy reactions were observed. Laboratory abnormalities attributed to CMX treatment consisted of 4 cases of elevated serum transaminase and 2 cases of elevated serum creatinine.     

Diagnostic value of different urine tests for urinary tract infection: a systematic review and meta-analysis

BackgroundThere are differences in specificity and sensitivity of different routine urine tests for urinary tract infection, so meta-analysis was used to compare the diagnostic value of various urine analysis and detection methods in urinary tract infection, including bacterial culture, urine sediment microscopy, automated urinalysis, and routine urine dry chemical methods.MethodsThe PubMed, Embase, Cochrane Library, SpringerLink, CNKI, and Wanfang databases were searched from inception to December 2021. Two system assessors independently screened the literature according to the inclusion and exclusion criteria. RevMan version 5.3 (the Cochrane Collaboration) and Meta-DiSc were used to calculate the combined sensitivity (Sen), specificity (Spe), positive likelihood ratio (LR+), negative likelihood ratio (LR–), and diagnostic ratio (DOR) of the diagnostic tests and draw summary receiver operating characteristic (SROC) curves.ResultsA total of 14 documents were included according to the inclusion and exclusion criteria. There was a significant statistical difference between the urine sediment microscopy group and the urine normalization group in urine leucocyte detection (OR =2.15, 95% CI: 1.29–3.56, P=0.003, I²=19%, Z=2.95), urine erythrocyte test (OR =1.87, 95% CI: 1.13–3.09, P=0.01, I²=0%, Z=2.45), quantitative determination of urinary protein composition (OR =2.32, 95% CI: 1.27–4.23, P=0.006, I²⁼30%, Z=2.73), and determination of urinary enzymes (OR =1.67, 95% CI: 1.03–2.72, P=0.04, I²⁼0%, Z=2.07).DiscussionWhen examining red and white blood cells in urinary tract infection diagnosis, urine dry chemistry is superior to automated urinalysis in terms of area under the curve (AUC), Sen, Spe, etc. When examining urine bacteria, urine dry chemistry can be recommended for urine bacteria screening, with bacterial culture required for confirmation.     

Evaluation of abnormal radiological findings in children aged 2 to 36 months followed by recurrent urinary tract infection: a retrospective study

Our aim is to determine the rational usage of imaging techniques in order to prevent or minimize permanent renal damage in recurrent urinary tract infections (UTIs). This study was enrolled children aged between 2 and 36 months, following-up with the diagnosis of recurrent UTI. All children had ultrasonography (USG) and dimercaptosuccinic acid scanning, 39 of them had underwent on voiding cystourethrography. There were 133 children (87 girls, 46 boys) with the mean age of 32.82?±?38.10 months included into the study. Forty-three kidney units were normal in ultrasonogram of which seven units had reflux whereas among 35 units with hydronephrosis 22 units had reflux. Sensitivity and specificity presence of hydronephrosis in ultrasonogram for prediction of reflux was 75.9% and 73.5%, respectively. There were 19 dilated ureters in ultrasonogram, and among them 14 had reflux. Sensitivity and specificity of presence with ureteral dilatation in ultrasonogram for prediction of reflux was found as 48.3% and 89.8%, respectively. The sensitivity of parenchymal thinning seen in ultrasonogram for the evaluation of renal parenchyma was 15.9%, whereas specificity was 98.2% .Sensitivity and specificity of dimercaptosuccinic acid for prediction of reflux was 51.6% and 72.3%, respectively. The normal ultrasonogram findings cannot rule out neither possibility of reflux presence nor development of renal scarring. Therefore, DMSA scanning has major role both in determination of parenchymal damage and prevention of scarring. Also we get an important result as ureteral dilatation seen in USG, related to presence of reflux.