Diagnostic usefulness of procalcitonin as a marker of bacteremia in patients with acute pyelonephritis

Abstract

Background. Acute pyelonephritis (APN) is one of the most common community-acquired infections and frequently accompanies bacteremia. The purpose of this study was to investigate the diagnostic role of procalcitonin in predicting bacteremia in patients with APN. Methods. We conducted a retrospective study of patients with APN who visited the emergency department (ED) at Samsung Medical Center, Seoul. Predictors of bacteremia were analyzed and receiver operating characteristics (ROC) curves were plotted for procalcitonin, C-reactive protein (CRP), and leukocytes. Results. During the study period, a total of 147 patients who had microbiologically proven APN and available initial procalcitonin concentrations were identified. Of these, bacteremia was present in 84 patients. Multivariate analysis showed that age, hypotension, and higher procalcitonin concentrations independently predicted the presence of bacteremia. Procalcitonin had better discriminative power than CRP, as reflected by area under the ROC curve analysis (0.746 [95% CI, 0.667–0.826] vs. 0.602 [95% CI, 0.509–0.694], p = 0.02). At a cut-off value of 1.63 μg/L, procalcitonin predicted bacteremia with a sensitivity, specificity, positive predictive value, negative predictive value and accuracy of 61.9, 81.0, 81.3, 61.4 and 70.1%, respectively. Conclusion. Procalcitonin concentration could be used as a reliable marker to predict bacteremia in patients with APN in the ED.     

Air in the kidney: between emphysematous pyelitis and pyelonephritis

Presence of air in the kidney can be problematic as the location of the air in different parts of the kidney greatly affects the subsequent management and outcome of the patient. We present here a case of a patient who had emphysematous pyelitis, in which CT scan was able to display presence of air only in the collecting system, thus differentiating this condition from the more fulminant emphysematous pyelonephritis. This leads to a more favourable prognosis and outcome to the patient.     

Change of antimicrobial susceptibility among Escherichia coli strains isolated from female patients with community-onset acute pyelonephritis

Purpose

There is a concern on which antimicrobials are appropriate as empirical agents for community-onset acute pyelonephritis (APN) in regions where the fluoroquinolone resistance rate is high, such as in Korea.

Materials and Methods

Three hundred and two strains of E. coli in 2001-2002 and 349 strains in 2008-2009 were isolated from the urine cultures of female adult APN patients, and the antimicrobial susceptibility was compared according to each study period. All the patients were classified as uncomplicated or complicated APN, and a subgroup analysis was done thereafter.

Results

The E. coli strains isolated in 2008-2009 showed improved susceptibility to trimethoprim-sulfamethoxazole compared to those isolated in 2001-2002. However, the third generation cephalosporin and gentamicin susceptibility was worsened. Of the 232 isolates from the uncomplicated APN patients, there was no difference between the two different time periods. On the other hand, of the 419 isolates from the complicated APN patients, the susceptibility to third generation cephalosporin, gentamicin and ciprofloxacin was significantly worsened.

Conclusion

The antimicrobial susceptibility of E. coli changed over the study period, however, this change occurred mainly in the complicated APN patients. In Korea, ciprofloxacin is still useful as an empirical agent for uncomplicated APN patients, but this is not the case for patients with complicated APN because of high resistance rate to ciprofloxacin in these patients. For the complicated APN patients, the rate of resistance to ciprofloxacin is already more than 30%.     

慢性肾盂肾炎患者骨代谢研究

目的 了解慢性肾盂肾炎患的骨代谢情况。方法 对31例慢性肾盂肾炎患进行了有关骨密度(Ward’s、Neck、Troch、L2-4)、血清骨钙素(BGP)、尿脱氧吡啶啉(DPD)、肾小球滤过率(TGFR)、血β2-MG、尿β2-MG等项目的检查,并将结果输入计算机,进行t检验及r直线相关等统计学处理。结果 患组血BGP(7．041±5．743ng／ml)、尿DPD(6．058±2．245nM／nMCr)、Ward’s三角部位骨密度(0．838±0．223g／cm^2)与对照组相比(分别为3．354±0．765ng／ml、4．596±1．621nM／nMCr、0.936±0．076g／cm^2)经t检验具有显差异性(P<0．05或P<0．01);而Neck、Troch、L2-4部位骨密度、血清Ca、P、Mg、AKP、BUN、Cr等项检查,患组与对照组无明显差异(P>0．05);患组Ward’s三有部位骨密度与TGFR、血β2-MG、尿β2-MG具有明显相关性(r系数分别为0．567、-0．500、-0．334,P<0.05)。结论 慢性肾盂肾炎患,即使没有发展到慢性肾功能不全阶段,也已存在骨代谢异常,应及早采取措施,避免骨质疏松的发生。     

尿中性粒细胞明胶酶相关脂质运载蛋白对儿童急性肾盂肾炎诊断价值的探讨

目的 探讨尿中性粒细胞明胶酶相关脂质运载蛋白（NGAL）对儿童急性肾盂肾炎（APN）的诊断价值。方法 研究对象为 2016 年 12 月—2017 年 5 月收治的尿路感染（UTI）患儿 104 例,包括急性肾盂肾炎 61 例（APN 组）及下尿路感染 43 例（非 APN 组）,均检测血清 β2 微球蛋白（β2-MG）、胱抑素 C（CysC）、C 反应蛋白（CRP）、降钙素原（PCT）和尿 NGAL 的水平,对比 2 组各指标的水平,并进行统计学分析;采用受试者工作特征（ROC）曲线分析各指标对 APN 的诊断价值。结果 APN 组血 CRP、PCT、β2-MG 及尿 NGAL 的水平均高于非 APN 组,差异有统计学意义（P＜0.05）;血 CysC 水平差异无统计学意义。血 CRP、PCT 及尿 NGAL 诊断儿童 APN 的 ROC 曲线下面积（AUC）分别为 0.838、0.898、0.963;血 CRP 最佳临界值为 22.6 mg/L 时,敏感度为 75.4%,特异度为 83.7%;PCT 最佳临界值为 0.285 μg/L 时,敏感度为 77.0%,特异度为 93.0%;当尿 NGAL 最佳临界值为 473 μg/L 时,敏感度为 82.0%,特异度为97.7%。结论 尿 NGAL 对儿童 APN 具有诊断价值,有助于临床对儿童 APN 的早期识别。     

FDA关于抗菌药物治疗复杂性泌尿道感染与肾盂肾炎临床试验的考虑

本文介绍了美国食品药品监督管理局(FDA)关于抗菌药物治疗复杂性泌尿道感染与肾盂肾炎临床试验的考虑。在开发药物以治疗这2种疾病时,应进行具有足够统计学意义和良好对照的试验,来确定其安全性和有效性,即其有效性较批准药物相似或更优效。这些研究中的主要有效性参数,应该是微生物学的检查结果,研究中应建立这些患者的临床治愈与细菌清除之间的总体相关性。     

Nephrectomy for Non-neoplastic Kidney Diseases

This review discusses the pathology of non-neoplastic kidney disease that pathologists may encounter as nephrectomy specimens. The spectrum of pediatric disease is emphasized. Histopathologic assessment of non-neoplastic nephrectomy specimens must be interpreted in the clinical context for accurate diagnosis. Although molecular pathology is not the primary focus of this review, the genetics underlying several of these diseases are also touched on.     

慢性肾盂肾炎大鼠模型的建立

目的创建一种慢性肾盂肾炎(CPN)大鼠模型.方法分别用108/ml(A组)、106/ml(B组)浓度致病性大肠杆菌(E.coli O111B4)株膀胱内注射,并短暂结扎左侧输尿管,观察7、15、30、60、90d肾脏形态学变化,肾组织及膀胱尿细菌培养,以及30、60、90d尿N-乙酰-β-D-氨基葡萄糖苷酶(NAG)/尿肌酐、血肌酐(Scr)、尿素氮(BUN)、24h尿蛋白定量的变化.结果随着感染性炎症的修复,左肾外观有皮质瘢痕及相关肾乳头收缩和肾盏的扩张,镜下慢性肾间质性肾炎改变和纤维化,以A组显著;A、B两组NAG/尿肌酐在第90日明显升高;细胞培养阳性结果主要在左肾和尿;其余项目与C组无差异.结论短暂结扎单侧输尿管和膀胱内接种一定剂量E.coli O111B4能够制备典型的CPN大鼠模型,以108/ml浓度为适宜.     

Ofloxacin: new applications for the prevention of urinary tract infections in renal graft recipients

C. Rafat, S. Vimont, P.Y. Ancel, Y.C. Xu‐Dubois, L. Mesnard, N. Ouali, M. Denis, A. Vandewalle, E. Rondeau, A. Hertig. Ofloxacin: new applications for the prevention of urinary tract infections in renal graft recipients
Transpl Infect Dis 2011: 13: 344–352. All rights reserved Abstract: Background. Urinary tract infections (UTIs), the most common form of bacterial infection in kidney transplant recipients, recently have been demonstrated to be detrimental for long‐term graft outcome. Therefore, reinforcing antibiotic prophylaxis might be vital, in addition to basic hygiene recommendations, surgical care, and prophylaxis by trimethoprim–sulfamethoxazole. Methods. In 2006, a Legionella pneumophila contamination of our department's water pipes meant that all the patients undergoing renal transplantation underwent a 1‐month regimen of ofloxacin (OFLO) (200 mg every other day). We took this opportunity to measure the incidence of UTI, including acute pyelonephritis (APN), in 100 consecutive patients transplanted before (n=50) and after (n=50) this treatment decision was reached. We also studied the antimicrobial resistance profiles in our department and in the rest of the hospital. Results. No patient developed Legionnaire's disease. A dramatic decrease in the incidence of UTI (?63%) was also seen in patients undergoing OFLO treatment. Logistic regression analysis demonstrated that the use of OFLO was independently associated with a reduction in UTI (odd ratio [OR]=0.31%, 95% confidence interval [CI] 0.11–0.84, P=0.02) and APN (OR=0.21%, 95% CI 0.07–0.98, P=0.045). This protection was sustained during the whole first year post transplantation. As for resistance rates, we observed a decrease in the susceptibility of Pseudomonas aeruginosa to ciprofloxacin in our nephrology department, compared with that observed in the rest of the hospital. The incidence of multi‐resistant bacteria was stable. Discussion. Our unintentional extension of prophylactic antibiotherapy with OFLO gave rise to a dramatic decrease in the 1‐year incidence of UTI and APN in kidney recipients. Emergence of resistant strains is, however, a major concern.     

Acute antepartum pyelonephritis in pregnancy: a critical analysis of risk factors and outcomes

Objective

To test the incidence and sonographic parameters of pyelonephritis during pregnancy, and to examine risk factors and pregnancy outcomes of women with acute antepartum pyelonephritis.

Study design

A retrospective population-based study comparing all singleton pregnancies of patients with and without acute antepartum pyelonephritis was performed. Patients lacking prenatal care as well as multiple gestations were excluded from the study. Multiple logistic regression models were used to control for confounders.

Results

Out of 219,612 singleton deliveries in 1988–2010, 165 women (0.07%) suffered from acute antepartum pyelonephritis. Abnormal sonographic findings were found in 85.7% of the patients with pyelonephritis. Pyelonephritis was significantly associated with nulliparity (46.1% vs. 24.4%, p < 0.001), younger maternal age (26.3 ± 6.0 vs. 28.6 ± 5.8 years, p < 0.001), intrauterine growth restriction (IUGR) (6.7% vs. 2.1%, p < 0.001), placental abruption (3.6% vs. 0.7%, p < 0.001), low 1 min Apgar scores (10.3% vs. 6.0%, p < 0.05), urinary tract infection (UTI) (4.2% vs. 0.4%, p < 0.001) and preterm delivery (less than 37 weeks gestation; 20.0% vs. 7.8%; p < 0.001). Using a multivariable analysis, independent risk factors for acute antepartum pyelonephritis were nulliparity (OR 2.0; 95% C.I 1.4–2.9; p < 0.001), UTI (OR 10.3; 95% C.I 4.8–22.1; p < 0.001) and younger maternal age (OR 0.96; 95% C.I 0.93–0.99; p = 0.009). Using another multivariable analysis, with preterm delivery as the outcome variable, acute antepartum pyelonephritis was found as an independent risk factor for preterm delivery (OR 2.6; 95% C.I 1.7–3.9; p < 0.001).

Conclusion

Acute antepartum pyelonephritis is associated with adverse perinatal outcomes and specifically is an independent risk factor for preterm delivery.