Acute and recurrent symptomatic urinary tract infections in women

Urinary tract infections remain a common problem affecting a wide population, especially adult females. The purpose of this paper is to provide an understanding of the pathogenesis, and to recommend practical approaches to therapy. Due to the size of the field, comments have been limited to acute and recurrent urinary tract infection in women.     

The lower urinary tract in pregnancy and the puerperium

Lower urinary tract symptoms are so common in early pregnancy that they are considered normal. Their progression throughout the antepartum period and their resolution postpartum has been documented by several authors. However the data are confusing and the underlying causes remain uncertain. Abnormal voiding patterns appear to be due to a combination of factors: pressure effects, changes in renal function and alterations in detrusor function. In addition, this review article identifies possible alternative causes for stress incontinence in pregnancy and suggests that the pathology may in fact be totally different from the stress incontinence which occurs in the postpartum period.     

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.

     

Distribution of afaE adhesins in Escherichia coli isolated from Japanese patients with urinary tract infection

PURPOSE: Afimbrial adhesin is known to be one of the most prevalent virulence factors in uropathogenic Escherichia coli. A recent report showed that the new subtype afaE8 predominated in afa positive isolates from patients with pyelonephritis (55.6%), suggesting that this subtype may be an important factor in ascending urinary tract infections. MATERIALS AND METHODS: A total of 457 E. coli strains consisting, of 194, 76 and 107 isolates from patients with cystitis, pyelonephritis and prostatitis, respectively, and 80 isolates from the rectal flora of healthy individuals were subjected to polymerase chain reaction to determine the afa operon as well as afaE subtypes.RESULTS: We identified 32 afa positive isolates of 377 strains (8.5%) and 2 of 80 strains (2.5%) from urinary tract infection isolates and normal flora, respectively. When afaE subtypes were determined, the afaE3 subtype predominated in afa positive isolates from cystitis (64.7%), pyelonephritis (66.7%) and prostatitis (50%). However, the afaE8 subtype was absent from urinary tract infection isolates, while only 1 isolate from the stool of a healthy adult harbored this subtype. CONCLUSIONS: Our data show that the afaE3 subtype predominated in pyelonephritis as well as in other urinary tract infections, indicating that the afa gene may be important in urinary tract infection. However, the distribution of afaE subtypes may be diverse in different areas of the world.     

Diagnosis of pediatric urinary tract infections

Urinary tract infection (UTI) is the second common infection in children. The diagnosis of UTI in infants and children can be difficult. Good history taking and physical examination are corner stones of good care of UTI. In addition, this article reviewed current evident on the methods of urine specimen collection and various diagnostic criteria to reach the diagnosis of UTI. Asian Guideline for UTI in children is highlighted to increase consensus of the diagnosis of UTI.     

Pediatric renal transplantation into the abnormal urinary tract

Many children with end-stage renal disease have significant urinary tract problems other than irreversible loss of native kidney function. These significant other urinary tract problems if not corrected prior to transplantation, may significantly increase recipient mortality, graft loss, and patient morbidity. These other urinary tract problems may cause hydroureteronephrosis in the transplanted kidney, lead to an increased incidence of graft rejection, be the source of sepsis after subsequent immunosuppression, and cause hypertension. In addition, pre-existing urinary diversion, large interabdominal masses, or previous cancer require specific pre-transplant management plans. Potential pediatric transplant recipients with other significant urinary tract problems can be classified according to three parameters: anatomical extent, pathology, and pathophysiology of the significant other problems. Particular attention must be paid to pre-existing lower tract problems. Strategy must be worked out pre transplant as to how the lower urinary tract is going to store, hold, and empty urine. The means for assessing the potential recipients and strategies and techniques for correcting pre-existing problems have been summarized in this article.     

Premenopausal women with recurrent urinary tract infections have lower quality of life

Objectives

To examine the impact on quality of life of recurrent acute uncomplicated urinary tract infection among premenopausal Singaporean women, and to determine the risk factors for lower quality of life among these patients.

Methods

A total of 85 patients with recurrent acute uncomplicated urinary tract infection who were referred to the Urology Department at the National University Hospital, Singapore, were prospectively recruited over a 3‐year period to complete the validated Short Form 36 Health Survey version 1. In addition, demographic and clinical details including symptomology and medical history were analyzed for factors impacting quality of life. Short Form 36 Health Survey version 1 results were compared with published population norms.

Results

After adjusting for age, gender and race, recurrent acute uncomplicated urinary tract infection patients had significantly lower quality of life on seven out of eight Short Form 36 Health Survey version 1 domains when compared with age‐, gender‐ and race‐adjusted population norms for Singapore. Among those with recurrent acute uncomplicated urinary tract infection, those who also reported caffeine consumption had significantly lower Short Form 36 Health Survey version 1 scores than those who did not. Those who reported chronic constipation also had consistently lower Short Form 36 Health Survey version 1 scores across all domains.

Conclusions

Recurrent acute uncomplicated urinary tract infection has a negative impact on the quality of life of premenopausal, otherwise healthy women. Recurrent acute uncomplicated urinary tract infection patients who also have chronic constipation or consume caffeine have lower quality of life than those who do not. More studies are required to understand the relationships between these common problems and risk factors.

     

膀胱镜检查与医源性尿路感染

为研究膀胱镜检查与医源性尿路感染的关系以及预防性应用抗菌药的意义,本文总结了117例膀胱镜检查资料,提出对检查前非感染尿病人,检查后不必常规预防性应用抗菌药;对检查前感染尿病人而尿细菌培养阴性者,建议检查后预防性应用抗菌药;对检查前尿细菌培养阳性者,尤其对于尿路梗阻或拟行输尿管插管的病人,建议检查前后应用有效的抗菌药。     

High prevalence of febrile urinary tract infections after paediatric renal transplantation.

BACKGROUND: Adult data suggest that urinary tract infections occur frequently after renal transplantation (RTx) and contribute to mortality and graft loss; data in children are limited. Therefore, we evaluated prevalence, short and long-term morbidity and confounding factors of febrile UTI (fUTI) after paediatric RTx. METHODS: In a retrospective cross-sectional study of three centres, we analysed data on 110 children followed for 4.9+/-3.4 years after successful transplantation. RESULTS: 40/110 (36%) patients had at least one fUTI at a median time of 0.98 years (range 0.02-8.96) after RTx; 11 patients (28%) had recurrent fUTI. Serum creatinine (SCr) rose significantly from 1.15+/-1.13 to 1.83+/-1.69 mg/dl, (P<0.001) during the fUTI, declining to baseline values after treatment. At the last followed-up calculated mean, GFR was comparable between fUTI and non-fUTI groups (75+/-26 vs 71+/-22 ml/min/1.73 m2). During fUTI mean, C-reactive protein (CRP) increased to 123+/-75 mg/l. Febrile UTI were significantly more frequent in girls compared to boys (22/44 vs 18/66, P<0.05) but occurred significantly earlier in boys than in girls [median 0.63 (range 0.02-4.15) vs 1.07 (0.04-8.96) years after RTx; P<0.02]. Also, patients with urinary tract malformations (UTMs) and neurogenic bladder as underlying diagnosis and those with urological surgery prior to transplantation had an increased risk for fUTI. CONCLUSION: fUTI is a frequent complication with significant short-term morbidity especially in girls and children with UTMs, neurogenic bladder and those with urological surgery. Long-term follow-up and prospective studies confirming specific risk factors, preventive measures and impact on graft survival are necessary.     

Management of urinary tract infections: historical perspective and current strategies: Part 2--Modern management

PURPOSE: An understanding of the microbial origin of infectious diseases and the introduction of antimicrobial therapy stimulated more advances in the management of urinary tract infections (UTIs) in the 20th century than had occurred in the previous 5 centuries. MATERIALS AND METHODS: Numerous resources were used to collect the information described in this review. Medical texts from the 19th and 20th century contain information regarding the traditional contemporary treatment of UTI during those eras. Early volumes of the Journal of Urology from the beginning of the 20th century describe the first attempts at chemotherapy for UTI. MEDLINE searches were used to collect appropriate information after 1969. Modern medical journals and modern medical texts were used to collect information on antimicrobial therapy since the late 1960s through today. RESULTS: Numerous advances in the diagnosis and management of UTI were made during the 20th century. Advances in microbiological and chemical assays have facilitated the development of historical uroscopy into modern day urinalysis and culture techniques, which are the cornerstone of UTI diagnosis. Imaging technologies, including x-ray, ultrasound, nuclear imaging, magnetic resonance and computerized tomography, have been particularly helpful in the diagnosis of complicated or recurrent UTIs. Major innovations in nonpharmacological therapy include noninvasive shock wave lithotripsy and percutaneous drainage of kidney abscesses. The most profound advance in UTI management during the 20th century was the discovery of antimicrobial agents. Nitrofurantoin was the first truly effective and safe antimicrobial therapy for UTI but its spectrum of activity is limited. Broad use of amoxicillin (and other beta-lactams) after its introduction in the 1970s led to the development of resistance to this antimicrobial, prompting a gradual change to trimethoprim/sulfamethoxazole (TMP/SMX) as first line therapy for UTI. However, wide use of TMP/SMX also resulted in the progressive emergence of resistance, limiting the clinical usefulness of this therapy in the modern management of UTI. Fluoroquinolones offer an attractive alternative to TMP/SMX, and American and European guidelines recommend their empirical use in areas where TMP/SMX resistance is 10% or higher. CONCLUSIONS: The development of antimicrobial therapy was the defining moment of 20th century medicine and one of the key innovations in medical history. While the initial promise of antimicrobials has been validated in clinical practice, overuse of certain agents has led to the emergence of resistance, illustrating the importance of using evidence based strategies to select therapy.     

Neurophysiology and neuropharmacology of the lower urinary tract

Recent advances in our understanding of the neurophysiology and neuropharmacology of the lower urinary tract have improved our ability to treat disorders of bladder and urethral function. Similarly, many classes of drugs currently used in treating various medical conditions can cause lower urinary tract symptoms and dysfunction. Based on objective modern techniques of urodynamic evaluation, the clinician is able to sort out bladder and urethral abnormalities and scientifically choose appropriate pharmacologic regimens to treat these conditions.This paper reviews lower urinary tract physiology, the neurophysiology of voiding mechanisms and provides the clinician with a rational, objective, current neuropharmacologic approach to lower urinary tract disorders.     

Epidemiology and risk factors for urinary tract infection in patients with spinal cord injury

PURPOSE: To our knowledge risk factors for urinary tract infection associated with various drainage methods in patients with spinal cord injury have never been evaluated overall in the acute period. We identified the incidence and risk factors associated with urinary tract infection in spinal cord injured patients. MATERIALS AND METHODS: We prospectively followed 128 patients at our spinal cord injury reference hospital for 38 months and obtained certain data, including demographic characteristics, associated factors, methods of urinary drainage, bladder type, urological complications and predisposing factors of each infection episode. Logistic regression modeling was done to analyze variables and identify risk factors that predicted urinary tract infection. RESULTS: Of 128 patients 100 (78%) were male with a mean age plus or minus standard deviation of 32 +/- 14.52 years. All patients had a nonfatal condition by McCabe and Jackson guidelines, and 47% presented with associated factors. The incidence of urinary tract infection was expressed as number episodes per 100 patients daily or person-days. The overall incidence of urinary tract infection was 0.68, while for male indwelling, clean intermittent, condom and female suprapubic catheterization, and normal voiding the rate was 2.72, 0.41, 0.36, 0. 34 and 0.06, respectively. The risk factors associated with urinary tract infection were invasive procedures without antibiotic prophylaxis, cervical injury and chronic catheterization (odds ratio 2.62, 3 and 4, respectively). Risk factors associated with repeat infection were a functional independence measure score of less than 74 and vesicoureteral reflux (odds ratio 10 and 23, respectively). CONCLUSIONS: Spinal cord injured patients with complete dependence and vesicoureteral reflux are at highest risk for urinary tract infection.