[An intravesical foreign body--the cause of chronic pyelonephritis in a child]

The paper reports on a case of chronic pyelonephritis with bacillus Proteus, generated by an intravesical foreign body (sewing needle). The needle was extracted with surgical cystoscope. After removing the foreign body, nalidixic acid was administered. The immediate evolution of the case was good.

Medullary sponge kidney and staghorn calculi

We describe a 65-year-old female with bilateral staghorn calculi who presented with a Proteus mirabilis perinephric abscess secondary to a ruptured lower pole hydrocalyx. Radiologic evidence was consistent with underlying medullary sponge kidney (MSK) disease. Despite expectations to the contrary, MSK, a disease notable for many risk factors capable of precipitating staghorn disease, is rarely associated with coexistent staghorn calculi. A discussion of the concurrent risk factors and a possible hypothesis regarding the lack of coexistence follows.

Splenic abscess as a complication of percutaneous nephrostomy

We report a case of splenic abscess as a complication of percutaneous nephrostomy tube placement. The patient was a sixty-three-year-old man suffering from a recurrence of transitional cell carcinoma of the bladder after cystectomy and neobladder substitution. Computed tomography of the abdomen identified the abscess, which was drained percutaneously. The patient's condition improved dramatically, and computed tomography showed complete resolution of the abscess two weeks after drainage. Splenic abscess is fatal if untreated and should be considered in a patient in whom sepsis or left lower pulmonary effusion develops after percutaneous manipulation of the kidney.

Formation of perinephric abscess following extracorporeal shock-wave lithotripsy

We report 2 cases of perinephric abscess formation following extracorporeal shockwave lithotripsy (ESWL). Possible mechanisms and preventative measures are discussed.

Late bacterial endophthalmitis following retinal detachment surgery

We report two cases of late postoperative bacterial endophthalmitis that occurred following retinal detachment repair. Both patients presented months after their scleral buckling procedures with a subacute uveitis. Over a period of one to two weeks, the inflammation gradually increased, until the classic clinical appearance of fulminant bacterial endophthalmitis was present. In an effort to treat the infection, a pars plana vitrectomy was performed in both cases. At the time of vitreous surgery, intrusion of the scleral buckling elements into the globe was observed, suggesting a possible means of entry for the infectious agent. Removal of the buckling elements, repair of the scleral defects, and injection of intravitreal antibiotics were performed as therapeutic interventions. Vitreous cultures were positive in both cases for Proteus mirabilis. Postoperatively the retina remained attached in both instances, and, in one case, the visual acuity returned to 20/20.

Chronic urinary tract infection and renal stones

In patients with bacteriuria and small and otherwise asymptomatic renal stones, the infection should be linked to the stone before surgical removal of the stone is considered. In this study the level of infection was determined by ureteric catheterisation. The method could discriminate between stone-related infections (70%) and infections confined to the lower urinary tract (30%) in virtually all of the patients. Even very small stones (3 mm) were shown to be the cause of decade-long bacteriurias. The results of operative stone removal were encouraging, with eradication of the infection in 87% of the patients with stone-related infection.

Bacteriuria following extracorporeal shock wave lithotripsy of infection stones

Extracorporeal shock wave lithotripsy effectively pulverizes infected (struvite) renal calculi. However, after treatment minute residual fragments that may harbor bacteria and cause persistent bacteriuria remain in the renal collecting system for months. We investigated prospectively the incidence of persistent Proteus mirabilis bacteriuria after extracorporeal shock wave lithotripsy among 15 consecutive women with Proteus mirabilis urinary tract infections and struvite calculi. All patients received parenteral gentamicin for 3 to 8 days (mean 4.7 days) immediately before and after extracorporeal shock wave lithotripsy. Oral antimicrobials then were administered for 14 to 34 days (mean 25 days). Ten patients have maintained a sterile urine or experienced urinary reinfection by other organisms during 8 to 19 months (mean 13 months) of subsequent bacteriological surveillance. Of these 10 patients 9 had residual fragments. Five patients had Proteus mirabilis bacteriuria after 1 to 7 months of surveillance, including 3 with residual fragments. The mean stone size, methods and duration of renal drainage procedures, and duration of antimicrobial therapy were similar for the 2 patient groups. Proteus mirabilis was isolated from the cultures of only 3 of 11 retrievable stone fragments. In contrast to intact infected renal calculi, residual stone fragments after extracorporeal shock wave lithotripsy often are susceptible to sterilization with antimicrobials.

The Dienes effect as an epidemiological tool in a paraplegic unit

The authors study the Dienes effect in 136 P.mirabilis and 2 P.vulgaris strains, isolated from different infection or colonization sites, in 27 spinal cord injured patients, admitted to a Paraplegic Unit, during a 9 month period. It is shown that 7 cross-infection and 18 cross-contamination episodes occurred, affecting 13 of 27 patients, which indicates the great spreading capacity of these microorganisms; 97% of the results obtained were observed once again after 6 months' storage of strains. In addition, in 7 of these strains their resistance to several antibiotics was cured by treating them with acriflavine salts, demonstrating that the Dienes effect persists even when resistance to antibiotics is modified; the authors conclude that the Dienes effect is an accurate stable epidemiological tool to identify cross-infections and its origins, and to facilitate the interruption of the chain of infection.

Circumcision and periurethral carriage of Proteus mirabilis in boys

Swabs were taken for culture from the periurethral area and urethral meatus in 124 uncircumcised and 60 circumcised boys. Proteus mirabilis was grown from 28 (22.6%) swabs from uncircumcised boys and from only one (1.7%) swab from circumcised boys. This supports the idea that the prepuce may be the source of proteus urinary tract infection.

A shift from acute to chronic spontaneous pyelonephritis in male MM mice associated with a change in the causal micro-organisms

Proteus mirabilis was the predominant cause of acute diabetes-associated pyelonephritis occurring spontaneously in male MM mice until they were segregated in a new environment. Thereafter Pasteurella pneumotropica and Streptococcus faecalis emerged collectively as the most common causal organisms, the pyelonephritis became more chronic and Proteus mirabilis isolates from faeces and urine produced atypical non-swarming colonies on blood agar plates. This did not account for the reduced pathogenicity of Proteus mirabilis; when MM males were returned to the original environment the pyelonephritis again became acute but was associated with the atypical type of Proteus mirabilis although the normal type was abundant in the environment. The MM mice were Caesarean-derived and cross-fostered shortly before their transfer to the second environment, which probably accounts for their changed microbial status, but the reason for the emergence of the atypical type of Proteus mirabilis is not understood. The acute nature of the male MM pyelonephritis when caused by Proteus mirabilis parallels the situation described in other animals and humans.

Urease-positive bacteriuria and obstruction of long-term urinary catheters

Long-term urethral catheterization (greater than or equal to 30 days), a management technique for urinary incontinence, results in polymicrobial bacteriuria. We frequently found urease-producing bacteria: of 1,135 weekly urine specimens from 32 long-term-catheterized patients, 86% had urease-positive bacterial species at greater than or equal to 10(5) CFU/ml. The most common species were Proteus mirabilis and Morganella morganii, each found in over half the specimens. P. mirabilis, but not other urease-positive species, was significantly associated with the 67 obstructions observed in 23 patients. M. morganii had a more complex association and in some way may protect the catheter from obstruction.

Uropathogenicity in rats and mice of Providencia stuartii from long-term catheterized patients

Providencia stuartii, a frequent and persistent isolate from the urinary tract of chronically catheterized elderly patients, is multiply antibiotic resistant and may cause fatal bacteremia in those patients. We studied P. stuartii strains in rats and mice to determine differences in uropathogenicity. Strains studied varied in expression of factors which contribute to pathogenicity of other bacterial species. Urinary tract responses following challenge with P. stuartii strain HO (factors expressed) were similar to responses reported for uropathogenic E. coli strains both in bacterial persistence and histologic change. In animals similarly challenged with P. stuartii strain RO (factors not expressed), responses were similar to those reported for non-uropathogenic E. coli strains. Results indicate that: a) animal model studies may be useful in differentiating P. stuartii strains based on uropathogenicity, b) P. stuartii uropathogenicity may be related to identifiable factors associated with virulence in other species, and c) the CBA mouse model appears to be the most suitable for studies of P. stuartii uropathogenicity.

Nosocomial infectious balanoposthitis in neutropenic patients

We have reported balanoposthitis as a source of fever and bacteremia in two neutropenic uncircumcised patients. The etiologic organisms were Pseudomonas aeruginosa in one case and Providencia stuartii in the other. In one patient, the diagnosis was delayed by the presence of a condom catheter. This emphasizes the importance of personal hygiene in uncircumcised men about to undergo immunosuppressive therapy, and the need for judicious use of condom catheters in such patients.

Outbreak of wound infections following outpatient podiatric surgery due to contaminated bone drills

An outbreak of podiatric infections due to an uncommon strain of Proteus mirabilis occurred following outpatient podiatric surgery. An evaluation of the operating room environment failed to reveal the strain of P. mirabilis from any site other than three bone drills. Thus the drills served as the reservoir for the organism that was subsequently inoculated onto the hands of the surgeon or directly to a patient during bone drilling. The gas sterilization procedure that was used to sterilize the drills was found deficient. No additional cases of P. mirabilis infection have been observed since the elimination of the contaminated drills.

Endotoxemia and bacteremia in patients following ultrasonic lithotripsy

The incidence of endotoxemia was studied in 17 patients who underwent ultrasonic lithotripsy (USL), and compared with the incidence in 11 patients who underwent transurethral resection (TUR) and in 8 patients who underwent other operations. Fourteen of 17 patients (82%) who underwent ultrasonic lithotripsy had endotoxemia. The incidence of endotoxemia after USL was significantly higher than that after TUR (9%) or after other operations (12.5%). Only 2 of the 17 patients (12%) who underwent USL had bacteremia. The organisms isolated were P. mirabilis and S. sanguis, respectively. Six of the 14 patients with endotoxemia after USL suffered high fever. These data suggest that endotoxemia is a factor which causes high fever after USL.

Role of internal fixation in infection of open fractures: studies with Staphylococcus aureus and Proteus mirabilis

Studies of infections in open fractures are described. The hamster was chosen as the experimental model. Osteotomies of the femur were created with an osteotomy saw. Some osteotomies were left to heal and others were fixed with an 0.9 mm K-wire. The infection rates in fixed and unfixed fractures were compared. The first group of hamsters with fixed and unfixed osteotomies was returned to cages with open wounds. There was no difference in the infection rate at 2 weeks. The second group was deliberately contaminated with Staphylococcus aureus and then returned to cages with open wounds. In this group, the infection rate at 2 weeks was lower in the internally-fixed fractures than in the unfixed fractures. The third group was deliberately contaminated with the gram negative organism Proteus mirabilis. In these animals, the infection rate was increased in the presence of the internal fixation device. The fourth group was deliberately contaminated with both Staphylococcus aureus and Proteus mirabilis. The infection rate in these animals was very high; Proteus was recovered from those animals with internal fixation and Staphylococcus was recovered from those animals without internal fixation. These studies in the hamster document the usefulness of this animal as an inexpensive and reproducible model for studying infection of open fractures. The hamsters tolerated the procedure well, and wound and fracture healing progressed satisfactorily.

Prevention of primary wound infection in neurosurgical patients: a 10-year study

Two neurosurgeons in private practice at three community hospitals followed a regimen of antimicrobial prophylaxis for 10 years. No primary wound infection occurred in a series of 2000 consecutive major operations. The study gives rise to certain recommendations for the prevention of postoperative sepsis in neurosurgical patients.

Comparison of long-term indwelling catheters and bed-pads in the treatment of urinary incontinence in elderly patients

Bed-pads and long-term indwelling catheters were compared in the treatment of urinary incontinence in two groups of eight elderly bedridden women. The same silicone catheter could be left in situ on average for 2 months. A detailed description of the changes of urinary bacterial flora in patients of both experimental groups is given. At the end of the 6 months' study all of the patients in both groups had significant bacteriuria (greater than or equal to 10(8) CFU/1), Proteus species being the most common pathogen in catheterised patients. The development of multiple resistance was observed in both groups, but it was more pronounced in the catheterised group. The indwelling catheter was more economical (P less than 0.001), but carried a higher risk of infection.

Providencia stuartii: a common cause of antibiotic-resistant bacteriuria in patients with long-term indwelling catheters

The long-term-catheterized urinary tract may offer a particular niche to Providencia stuartii, which is otherwise an uncommon clinical isolate. Published accounts of bacteriuria in patients catheterized for long periods indicate that P. stuartii has often been found as frequently as familiar uropathogens such as Escherichia coli, Proteus mirabilis, enterococcus, and Pseudomonas aeruginosa. As in most nosocomial infections, the frequency of isolation of a given species has commonly differed among institutions. In the future P. stuartii may be more frequently encountered as a nosocomial pathogen in nursing homes and in acute care hospitals to which bacteriuric patients are transferred. This trend appears likely because of the increasingly large nursing-home population, the predilection of the bacterium for the long-term-catheterized urinary tract, the opportunity for nosocomial transmission from this reservoir, the resistance of the organism to multiple antibiotics, and the occasional systemic illness and bacteremia caused by P. stuartii.