Prophylactic ciprofloxacin for catheter-associated urinary-tract infection

Patients receiving antibiotics during bladder drainage have a lower incidence of urinary-tract infections compared with similar patients not on antibiotics. However, antibiotic prophylaxis in patients with a urinary catheter is opposed because of the fear of inducing resistant bacterial strains. We have done a double-blind, placebo-controlled trial of prophylactic ciprofloxacin in selected groups of surgical patients who had postoperative bladder drainage scheduled to last for 3 to 14 days. Patients were randomly assigned to receive placebo (n = 61), 250 mg ciprofloxacin per day (n = 59), or 500 mg ciprofloxacin twice daily (n = 64) from postoperative day 2 until catheter removal. 75% of placebo patients were bacteriuric at catheter removal compared with 16% of ciprofloxacin-treated patients (relative risk [RR] [95% CI] 4.7 [3.0-7.4]). The prevalence of pyuria among placebo patients increased from 11% to 42% while the catheter was in place; by contrast, the rate of pyuria was 11% or less in patients receiving ciprofloxacin (RR 4.0 [2.1-7.3]). 20% of placebo patients had symptomatic urinary-tract infections, including 3 with septicaemia, compared with 5% of the ciprofloxacin groups (RR 4.0 [1.6-10.2]). Bacteria isolated from urines of placebo patients at catheter removal were mostly species of enterobacteriaceae (37%), staphylococci (26%), and Enterococcus faecalis (20%), whereas species isolated from urines of ciprofloxacin patients were virtually all gram-positive. Ciprofloxacin-resistant mutants of normally sensitive gram-negative bacteria were not observed. Ciprofloxacin prophylaxis is effective and safe in the prevention of catheter-associated urinary tract infection and related morbidity in selected groups of patients requiring 3 to 14 days of bladder drainage.

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.

Prediction of septicemia following endourological manipulation for stones in the upper urinary tract

We investigated 117 patients undergoing percutaneous nephrolithotomy, percutaneous nephrostomy, ureterorenoscopy, the push-back or push-bang procedure for ureteral stones, Double-J* ureteral stenting plus extracorporeal shock wave lithotripsy (ESWL), ESWL alone or cystoscopy. Blood samples obtained before, during and 1 hour after the procedure were cultured and assayed for endotoxin and tumor necrosis factor. Also, culture was done of the urine preoperatively and postoperatively, and the stones when they could be retrieved. There was a temporal relationship among bacteremia, endotoxemia and elevation of tumor necrosis factor. An unexpected finding was peroperative endotoxemia in a significant number of patients with stones. Risk factors noted for postoperative bacteremia, endotoxemia and/or elevation of tumor necrosis factor included preoperative endotoxin level, type of procedure, presence of preoperative bacteriuria and pyuria. With respect to the procedure the risk was greatest after the push-back method and least after cystoscopy (push-back method greater than percutaneous nephrolithotomy/percutaneous nephrostomy greater than Double-J stenting plus ESWL greater than ureterorenoscopy greater than ESWL greater than cystoscopy). If the risk factors are measured preoperatively it may be possible to identify the risk of postoperative bacteremia/endotoxemia and, therefore, septic shock postoperatively. Our patients appear to be a good clinical model to investigate the problems related to septicemia.

Streptococcus agalactiae as a urinary tract pathogen in males and non-pregnant females

The role of Streptococcus agalactiae (group B streptococci, GBS) was investigated for a period of one year in different clinical forms of urinary tract infection in males and non-pregnant females over 14 years of age. The pathogen has been isolated in quantities of greater than or equal to 10(5) cfu/ml in midstream voided urine from 32 patients with clinical signs of urinary tract infection and pathologic urinary sediment. In every group of B isolates the antibiotic sensitivity to antimicrobial agents was determined by the single disk method of Kirby-Bauer. GBS with the same characteristics were established in urethral specimens of 4 males as well as in the vagina and faeces of 11 females. As a rule, peroral treatment with ampicillin proceeded successfully. In addition, women with streptococcal vaginitis were treated topically with 2% solution of chlorhexidine. Our results have demonstrated that GBS might cause urinary tract infection, but the evaluation of GBS isolated in urine specimens is complex.

[Kidney transplantation with cutaneous continent urinary diversion (apropos of 6 cases)]

In a series of 525 renal transplantations performed between January 1987 and September 1990, 5 patients (i.e. 1%) presented with vesical, sphincteric and urethral lesions which prevented classical uretero-vesical or uretero-ureteric reimplantation and functionally satisfactory vesico-sphincteric reconstruction. Under these conditions, in which drainage of the urine into the bladder was impossible, a diversion was created using a continent intestinal reservoir constructed prior to the graft. Four Kock pouches and one Mainz pouch were created during the months preceding renal transplantation with a cadavre kidney. A sixth patient, transplanted in 1981, had to undergo continent urinary diversion in February 1988 after a non-functional bladder augmentation for problems of bladder drainage. We did not observe any mortality or major medical or surgical complications. The follow-up after transplantation in the first 5 patients is now 3, 6, 10, 37 and 40 months. Renal function is normal in all 5 cases with serum creatinine below 130 mmol/l. For the sixth patient, the follow-up is 9 years after the transplantation and 32 months after the continent urinary diversion; serum creatinine is 200 mmol/l and stable since the urinary diversion. Continence is excellent and the comfort of all of the patients is undeniable. However, all patients present with bacteriuria with no symptomatic urinary tract infection.

Diagnostic and genetic studies in 43 patients with classic cystinuria

We present results for laboratory screening and diagnostic tests--cyanide-nitroprusside test, semi-quantitative thin-layer chromatography, and quantitative amino acid column chromatography--of 43 patients with classic cystinuria. We report the efficaciousness of the cyanide-nitroprusside test and of thin-layer chromatography, as compared with quantitative amino acid chromatography, for detecting heterozygotes for type II or III cystinuria. The quantitative results for aminoaciduria in 57 blood relatives in 23 families were used to categorize the index patients with classic cystinuria. By column chromatography the ranges of excretion rates (mumol/24 h per 1.73 m2 body surface area) of diagnostic amino acids in the index patients were as follows: cystine 556-54044 (normal 20-128), arginine 131-11543 (10-80), lysine 768-21848 (51-514), ornithine 185-5685 (0-80). Also by column chromatography the median values for arginine and ornithine excretion in cystine-lysinuric heterozygotes (among the 57 blood relatives) were significantly higher (P less than 0.01) than in controls but never approached the values for homozygotes. The cyanide-nitroprusside test results were positive in urine samples of 41 of 43 index patients and in 16 (51.6%) of the urine samples of 31 obligate heterozygotes with column chromatographically proven cystine-lysinuria. Thin-layer chromatography detected all of the homozygotes, all the compound heterozygotes, and 54.8% of the carriers. According to the type of aminoaciduria in their relatives, 11 patients with classic cystinuria could be classified as having classic cystinuria type I, 11 as having type II or III, and three as being compound heterozygotes. We discuss the implications of these results for correct diagnoses and for genetic studies in classic cystinuria.

[Trimethoprim VUFB in the therapy of urinary infections]

Twenty women with asymptomatic significant bacteriuria took Trimethoprim (TMP) VUFB, 2 X 200 mg, for eight days. Twelve had morphological changes of the urinary pathways confirmed by intravenous pyelography. The test for the presence of bacteria with an antibody film in the urinary sediment suggested that the infection was in the upper urinary pathways in eight of the women. Immediately after termination of treatment the urine was negative in 16 women (80%), after another three weeks the negative finding persisted in the urine of nine women (45%). In one patient treatment was discontinued after five days on account of dyspeptic complaints, the remaining patients tolerated the drug well.

Oral immunotherapy in paraplegic patients with chronic urinary tract infections: a double-blind, placebo-controlled trial

In a 6-month, double-blind, placebo-controlled clinical trial with cross-over, we investigated the efficacy and tolerance of an orally administered bacterial extract in 70 spinal cord injury patients with chronic lower urinary tract infections. In the treated patients, compared to those given placebo, there was a statistically significant decrease in the degree of bacteriuria, a considerably decreased incidence of infectious episodes and a lesser requirement for antibiotics.

Isolation of Neisseria gonorrheae and concomitant bacterial microflora from urine obtained by suprapubic bladder puncture in women with gonococcal urethritis

The authors examined 38 non-pregnant women with gonococcal urethritis. Thirty-three (86.8%) of them suffered also from endocervical gonorrhea. Neisseria gonorrheae (N. go) was isolated from the midstream of urine in a quantity of 1 x 10(2) to 9 x 10(8) in 1 ml of urine with an average of 5.08 x 10(4) N. go per 1 ml of urine and S. E. M. +/- 3.85 x 10(4) N. go per 1 ml of urine. On the basis of suprapubic puncture ascendent propagation of bacteria to the bladder was observed by cultivation in 13 (34.2%) patients, with isolation of N. go in 5 cases.

Detection of endotoxiuria in polycystic kidney disease patients by the use of the Limulus amebocyte lysate assay

Urinary tract infections (UTI) due to gram-negative bacteria are a serious complication in patients with polycystic kidney disease (PKD). Endotoxin, a component of the cell wall of gram-negative bacteria, has been reported to be pro-cystogenic in experimental animals. Because endotoxin levels in urines (endotoxiuria) from PKD patients have not been reported, the Limulus amebocyte lysate (LAL) assay, which detects picogram quantities of endotoxin, was used to probe for this cyst-promoting chemical. Fifteen PKD patients (seven females, eight males), asymptomatic for UTI, were tested and compared with 10 female and 10 male controls. All urines were assessed for (1) evidence of aerobic bacteria by routine quantitative cultures, (2) bacteria and pyuria by microscopic examination of gram-stained urine, and (3) bacterial endotoxin by the LAL assay. LAL tests were positive in 73% (11/15) of PKD patients, but only 25% (5/20) of controls (P = 0.0058). There was no significant difference in test positivity between PKD females (71%) and males (75%). There was no correlation of age, degree of renal dysfunction, or urine osmolality with endotoxiuria. Routine quantitative cultures were negative for gram-negative bacteria in PKD patients and all controls (except one female), as were microscopic findings for intact bacteria and pyuria. Thus endotoxiuria, in the absence of classical signs, symptoms, and microbiological findings of UTI, raises the possibility that endotoxin is available intrarenally to promote cystogenesis even before a potential susceptibility of PKD patients to classical UTI is manifested. Sources of urinary endotoxin observed in PKD patients, such as cryptic intrarenal sites or leakage from the gastrointestinal (GI) tract, remain to be defined.

Nonrefluxing colonic conduits: a long-term life-table analysis

We evaluated 25 patients undergoing urinary diversion with a nonrefluxing colonic conduit. Renal scarring developed in 10% of the kidneys during a median followup of 12.7 years. In 11 renal units (22%) deterioration of the ureteroenteric anastomosis occurred due to the development of reflux or stricture. Of these kidneys 45% had scarring; no renal unit in which the anastomosis remained intact had renal scars (p less than 0.001). Of our patients 96% had bacterial colonization of the colonic conduit but this was not associated with renal scarring if the urinary diversion was anatomically intact.

Urinary lactic dehydrogenase isoenzyme analysis in children with spinal lesions

In 48 children with spinal lesions and micturition problems urinary lactic dehydrogenase (LDH) isoenzymes were analyzed. They had higher total LDH activities (716.8 +/- 1,050.2 nkat/I), isoenzymes V percents (22.2 +/- 13.0%) and isoenzyme V activities (203.4 +/- 308.4 nkat/I) than those of healthy children (150.0 +/- 83.4 nkat/I, 1.9 +/- 1.0%, 5.0 +/- 3.3 nkat/I). Many subjects had an isoenzyme V-dominant LDH isoenzyme pattern. Among 48 subjects the patients with pyuria, bacteriuria or abnormal pyelograms had markedly high total LDH activities, isoenzyme V percents and isoenzyme V activities. The rise in LDH isoenzyme V levels may reflect the renal damage in the patients with neurogenic bladders.

Absence of factors associated with significant urinary tract infections caused by coagulase-negative staphylococci

Coagulase-negative staphylococci, excluding Staphylococcus saprophyticus, have recently been implicated as pathogens in urinary tract infections, especially in catheterized patients. In order to evaluate any laboratory markers for significant isolates of coagulase-negative staphylococci, we prospectively studied 72 patients with significant, indeterminant, or contaminant urine isolates of coagulase-negative staphylococci. Patients in the three categories did not differ by age, sex, presence of a urinary catheter, or other instrumentation or likelihood of nosocomial acquisition. The isolates from these three groups of patients were similar in antibiotic susceptibility and ability to produce slime. Overall, slime-producing coagulase-negative staphylococci were more likely to be S. epidermidis than any other species, but slime production was not associated with presence of pyuria, symptomatic urinary tract infection, instrumentation, nosocomial acquisition, or multiple antibiotic resistance. In this prospective study, no demographic characteristics or laboratory markers of coagulase-negative staphylococci were associated with clinical significance, as defined by symptoms or the presence of pyuria.

Detection of bladder bacteriuria in patients with acute urinary symptoms

Quantitative culture of midstream urine fails to yield a significant microorganism in many patients with acute urinary symptoms. We cultured bladder urine, obtained by aspiration, from symptomatic adults with equivocal findings on standard testing of midstream urine for low numbers of conventional uropathogens and fastidious bacteria. We found 561 (31%) of 1817 women and 36 (12%) of 300 men to be culture positive. Five hundred eighty-one (70%) of 830 isolates were fastidious bacteria; 191 (34%) of 561 culture positive women and 0 of 36 culture-positive men had polymicrobic bacteriuria. Bacterial counts were less than 10(5) colony-forming units/mL in 67% of samples; 204 of 406 patients with single-species infections had increased leukocyte counts in urine. Patients with symptoms of urinary tract infection who are culture negative on standard testing may harbor fastidious bacteria or low numbers of conventional uropathogens in the bladder. In these patients, culture of bladder aspiration urine for low counts and fastidious species is necessary to diagnose bacteriuria.

Evaluation of the modified Bac-T-Screen and FiltraCheck-UTI urine screening systems for detection of clinically significant bacteriuria

Previous evaluations of the Bac-T-Screen system (Vitek Systems, Inc., Hazelwood, Mo.) demonstrated excellent sensitivity with specimens from patients with clinically significant bacteriuria (including infections with small numbers of uropathogens) but poor specificity with specimens from noninfected patients. In the study reported here, the sensitivity and specificity of the Bac-T-Screen system with a modified decolorizing reagent were evaluated. A manual filtration system, FiltraCheck-UTI (Vitek Systems), for screening urine specimens, Gram stains of mixed urine specimens, and quantitative cultures were also evaluated. The test sensitivity for clinically significant bacteriuria was greater than 96% with the original Bac-T-Screen system as well as the modified system and the manual system. In comparison, the sensitivities of the Gram stains and quantitative cultures (greater than or equal to 10(5) CFU/ml) were 82 and 77%, respectively. Of the 375 patients classified as noninfected by clinical parameters, 34% had positive screening tests with the original Bac-T-Screen system, as compared with 13 and 11% with the modified Bac-T-Screen and FiltraCheck-UTI systems, respectively. Thus, the modified Bac-T-Screen system and the manual FiltraCheck-UTI system have sensitives comparable to that of the original Bac-T-Screen system and markedly improved test specificities.

Urinary infection may invalidate the double-sugar test of intestinal permeability

To assess the effect of urinary infection on a typical double-sugar test of intestinal permeability, rhamnose and cellobiose were added to 12 infected urine samples to give sugar concentrations generally present in the 5-h urine samples of patients undergoing the test. Rhamnose concentration fell by approximately 20% in two of the specimens after incubation at 37 degrees C for 5 h. Eight of the 12 samples showed a fall in cellobiose concentration at 2.5 h, and 11 at 5 h. On five occasions more than 90% of the cellobiose was destroyed within 5 h. Yet only eight of these urine samples contained organisms that were able to metabolize cellobiose. This apparent anomaly may have resulted from bacteria surviving in spite of the thiomersal preservative, and then consuming the glucose to which the cellobiose was hydrolysed to enable calculation of cellobiose concentration. We conclude that bacteriuria may invalidate the result of the double-sugar test of intestinal function.

Infection control in a skilled nursing facility: a 6-year survey

In 1981 an infection control programme was started in a 320-bed skilled nursing facility in The Netherlands. The programme consisted of recording the antimicrobial drugs prescribed and the site of infection, culture of urine from patients admitted from hospital and from residents with suspected symptomatic urinary tract infection, restriction of long-term indwelling urethral catheterization and restricted use of antimicrobial drugs. At a weekly staff meeting, these data were reviewed. As a result of the programme, the number of treatments for urinary tract infections decreased by 74% between 1981 and 1986, and the number of courses for recurrent urinary tract infections decreased from 18 to 6% of the total number given. The patients who did not require antimicrobial therapy increased from 51% in 1981 to 70% in 1986.

The urethral syndrome

The urethral syndrome is defined as lower urinary tract symptoms in women in the absence of bladder bacteriuria. It is a common disorder in general practice in Saudi Arabia. The aetiology and pathogenic factors involved in its development are still incompletely understood. Many factors have been suggested as causative of this syndrome, including non-specific infections, urethral obstruction and spasm, senile atrophy, psychosomatic and traumatic factors. An aetiological diagnosis should be made if possible and this will depend on clinical examination, mid-stream urine specimen for quantitative culture and microscopy. Cervical and urethral swabs for microscopy and culture are necessary when infection with urethral pathogens such as C. trachomatis and N. gonorrhoea is suspected. Urethral calibration and uroflowmetry may be needed in some patients. Treatment with a course of tetracycline is indicated for patients with urethral syndrome who have pyuria, urethral dilatation for patients with urethral syndrome secondary to stenosis, and skeletal and smooth muscle relaxants when spasm is found to be the cause. Local vaginal oestrogen application is effective in the treatment of urethral syndrome secondary to hypoestrogenaemia.