Plasma endotoxin concentrations in patients with urinary tract infections

BACKGROUND

Although endotoxin elicits a variety of pathophysiological activities in hosts with gram-negative bacterial infections, the clinical significance of plasma endotoxin levels have not been clearly defined in the patients with urinary tract infections. The purpose of the study was to measure plasma endotoxin concentrations in relation to the types of urinary tract infections and to examine their correlation with inflammatory parameters.

METHODS

Using chromogenic Limulus-amebocyte lysate assay, plasma endotoxin concentrations were measured in a total of 63 patients with various types of nonspecific urinary tract infections.

RESULTS

The mean plasma endotoxin concentrations in patients with sterile pyuria, chronic complicated cystitis, acute uncomplicated pyelonephritis or acute exacerbation of chronic complicated pyelonephritis, chronic complicated pyelonephritis, and acute bacterial prostatitis or epididymitis were significantly higher than those in healthy individuals and in patients with acute uncomplicated cystitis. The correlation coefficients between plasma endotoxin concentrations and body temperatures, white blood cell counts in peripheral blood, erythrocyte sedimentation rates, and C-reactive proteins were 0.678 (P < 0.01), 0.503 (P < 0.01), and 0.330 (P < 0.01), respectively.

CONCLUSIONS

Patients with urinary tract infections may respond to endotoxin locally and generally depending on the sites of infection involved. However, endotoxin levels do not always correlate to clinical findings or inflammatory parameters.

The impact of the first notification of positive blood cultures on antibiotic therapy. A one-year survey

The impact on antibiotic therapy of the first notification of positive blood cultures was assessed for 735 episodes of bacteraemia detected during 1992 in the County of Northern Jutland, Denmark. A primary focus of infection was defined in 498 episodes, the urinary tract being the most frequent (n = 182, 25%). Twenty-nine patients (3.5%) had died prior to the initial contact. In 12 episodes antibiotic therapy had either been stopped or data were not available, leaving 694 episodes for further assessment. In 567 episodes antibiotic therapy had been started prior to the initial contact, the most frequent regimen being ampicillin or an ampicillin-aminoglycoside combination (295 episodes), whereas cephalosporins, thienamycin, and fluoroquinolones were seldom used (41 episodes). The ongoing antibiotic coverage was deemed appropriate in 418 episodes (60%), non-optimal in 90 (13%), and lacking in 186 (27%). The notification of positive blood cultures elicited changes in antibiotic therapy in 315 episodes (45%), including commencement of antibiotic therapy in 127 (18%). Thus, blood culture results have a measurable impact on antibiotic therapy.

Variation of blood group antigen expression on vaginal cells and mucus in secretor and nonsecretor women

The expression of blood group antigens on the surface of urothelial cells and in mucus is controlled partly by the blood type and secretor status of the individual. To our knowledge, the possibility that the levels of these antigens vary with time has not been previously assessed. We determine if the pattern and/or intensity of blood group antigen expression on vaginal epithelial cells and mucus changed with time. Cell and mucus specimens were collected weekly for 3 months from 10 women: 5 (2 secretors and 3 nonsecretors) with and 5 (3 secretors and 2 nonsecretors) without a history of urinary tract infections. In addition, samples were collected on 5 consecutive days from 5 of these individuals. The cell and mucus samples were assayed for ABH and Lewis blood group antigens using monoclonal antibodies in cell concentration immunofluorescence and enzyme-linked fluorogenic assays, respectively. Although the pattern of antigen expression in the vaginal cell and mucus samples was consistent with the blood type and secretor status of an individual, in all women the level of antigen expression changed significantly and rapidly during the 3-month and 5-day periods. The results show a previously unrecognized phenomenon and demonstrate that the expression of blood group antigens on vaginal cells and in mucus is a dynamic process.

[Serum granulocyte-colony stimulating factor (G-CSF) levels in elderly patients with infections]

To clarify the clinical role of granulocyte-colony stimulating factor (G-CSF), we examined the levels of serum G-CSF in elderly patients with infection (n = 48) and elderly normal volunteers (n = 32). G-CSF levels were significantly higher in patients in acute infectious status (571.9 +/- 782.9 pg/ml, mean +/- SD) than in normal volunteers (25.3 +/- 19.7 pg/ml). There was no significant relationship between serum G-CSF levels and age or granulocyte count in normal volunteers. In acute infectious status, there was no relationship between serum G-CSF levels and granulocyte count or c-reactive protein (CRP). We compared the response of G-CSF to infection between patients with frequently repeated infection (repeaters) and others (non-repeaters). Repeaters showed relative lower elevation of G-CSF levels in acute infectious status compared with non-repeaters (197.6 +/- 370.0 pg/ml vs. 1014.1 +/- 927.4 pg/ml p < 0.001). In other clinical data, serum albumin was significantly lower in repeaters than in non-repeaters. There was no significant difference in age, serum total protein, white blood cell count, granulocyte count and CRP. In non-repeaters, G-CSF levels was significantly higher in acute phase of infection than in recovery phase (550 +/- 703 pg/ml vs. 37.5 +/- 39.2 pg/ml p < 0.01 n = 15). We determined the status which showed incomplete recovery of infectious symptoms as chronic phase. In twenty-two of repeaters, we examined serum G-CSF levels and clinical data in acute and chronic phase of infection. There was no significant difference in G-CSF levels between in acute and chronic phase.(ABSTRACT TRUNCATED AT 250 WORDS)

The role of C-reactive protein and erythrocyte sedimentation rate in the diagnosis of infected hydronephrosis and pyonephrosis

Serum C-reactive protein levels and erythrocyte sedimentation rates were prospectively evaluated in 38 patients with dilated pyelocaliceal systems in an attempt to distinguish simple hydronephrosis from infected hydronephrosis and pyonephrosis. The clinical presentations of infected hydronephrosis and pyonephrosis were extremely variable, ranging from no constitutional complaints to urosepsis. Renal sonography detected only 6 of 16 patients with pyonephrosis (specificity 96%, sensitivity 38%, accuracy 72.5%). Using a cutoff value of 3.0 mg./dl. for C-reactive protein and 100 mm. per hour for erythrocyte sedimentation rate, the diagnostic accuracy of detecting infected hydronephrosis and pyonephrosis increased to 97%, with a specificity of 89% and sensitivity of 100%. Based on our experience, we believe that the serum C-reactive protein and erythrocyte sedimentation rate levels can be used as screening tests to distinguish pyonephrosis and infected hydronephrosis from simple, uncomplicated hydronephrosis.

Association of Lewis blood group phenotypes with urinary tract infection in children

Many blood group antigens, genetically controlled carbohydrate molecules, are found on the surface of uroepithelial cells and may affect bacterial adherence and increase the frequency of urinary tract infection (UTI) in adults. Sixty-two children aged 2 weeks to 17 years (mean, 2.3 years) who were hospitalized with fever in association with UTIs caused by Escherichia coli had complete (n = 50) or partial (n = 12) erythrocyte antigen typing to determine the role of erythrocyte antigens and phenotypes in UTI in children; 62 healthy children undergoing nonurologic elective surgery, matched 1 to 1 for age, sex, and race to the patient group, formed the control group. In univariate tests, patients and control subjects did not differ in ABO, Rh, P, Kell, Duffy, MNSs, and Kidd systems by the McNemar test of symmetry (p > 0.05). The frequency of the Lewis (Le) (a-b-) phenotype was higher (16/50 vs 5/50; p = 0.0076) and the frequency of the Le(a + b +) phenotype was lower (8/50 vs 16/50; p = 0.0455) in the patient population than in the control subjects. A stepwise logistic regression model to predict UTI with the explanatory variables A, B, O, M, N, S, s, Pl, Lea, and Leb showed that only the Lea and Leb antigens entered the model with p < 0.1. The Le(a-b-) phenotype was associated with UTI in this pediatric population. The relative risk of UTI in children with the Le(a-b-) phenotype was 3.2 (95% confidence interval, 1.3 to 7.9). Specific blood group phenotypes in pediatric populations may provide a means to identify children at risk of having UTI.

[The clinical efficacy of the new drug agent ligentén in urology patients]

A clinical trial was made of a new gel ligenten intended for local urethral anesthesia and treatment of infection and inflammation in the lower urinary tracts. Ligenten was given to 52 patients to manage bladder, prostate, urethral infection and inflammation, for local prophylaxis before cystoscopy, urethral bouginage and transurethral surgery. Apparent advantages of intraurethral introduction of the analgetic compared to instrument lubrication are demonstrated. Ligenten was also effective against chronic cystitis, cystalgia and urethral syndrome in females, especially in ulcerative cystitis. The gel exhibited adequate antiinflammatory and analgetic effect. As a prophylactic means, it prevents inflammation in cystoscopy, urethral catheterization and transurethral operations. No severe side effects have been reported.

Intravesical instillation of gentamicin sulfate: in vitro, rat, canine, and human studies

OBJECTIVE

Intravesical instillation of gentamicin sulfate has been used empirically as prophylaxis and to treat bacilluria in spinal-cord-injured patients undergoing clean intermittent catheterization. To assess the risks of absorption and the effects of storage conditions on antimicrobial potency, a series of studies were conducted.

METHODS

Four studies were carried out: (1) An infected fulgurated rat bladder model was created to determine the effects of inflammation and infection on absorption. (2) A canine model with bilateral vesicoureteral reflux and elevated bladder pressures (> 40 cmH2O) assessed the effects of reflux and storage pressure. (3) The effects in patients with associated conditions including renal transplantation, myelomeningocele, vesicoureteral reflux, and bladder augmentation, were analyzed. (4) To determine the effects of storage conditions, solutions of gentamicin sulfate (480 mg gentamicin sulfate in 1 L 0.9% NaCl) were made that controlled for pH, storage temperature, and duration.

RESULTS

(1) Increased absorption was found in 43 percent of rat serum samples. (2) None of the dogs demonstrated measurable absorption. (3) None of the patients likewise had measurable absorption. (4) All solutions were equally potent when tested against a panel of common urinary pathogens. Storage up to two months at room temperature without alkalinization had no effect on potency.

CONCLUSIONS

Instilled intravesical gentamicin sulfate has a low risk of absorption and is highly effective. Severe bladder inflammation can increase transvesical absorption. It has prolonged stability without special storage conditions and should be considered as a route of prophylaxis in patients who perform intermittent catheterization.

Ciprofloxacin as prophylaxis for urinary tract infection: prospective, randomized, cross-over, placebo controlled study in patients with spinal cord lesion

To evaluate the efficacy of low-dose long-term treatment with ciprofloxacin in the prevention of recurrent urinary tract infections in patients with spinal cord lesions and neurogenic bladder dysfunction, a prospective, randomized, cross-over, placebo-controlled study was performed. The study period was 12 months long, including 6 months of treatment with 100 mg. ciprofloxacin at night and 6 months of placebo treatment. The study was completed by 18 men and 3 women, median age 38 years (range 19 to 73 years). Within the last 12 months before inclusion into the study, the patients had between 3 and 14 urinary tract infections (mean 5.8) treated with antimicrobial agents. The number of urinary tract infections treated with antimicrobial agents during 6 months of ciprofloxacin prophylaxis was 5 and during the 6 months of placebo treatment it was 59 (p < 0.00005) [corrected]. Fecal specimens showed supercolonization with ciprofloxacin resistant bacteria (Acinetobacter calcoaceticus) in 1 instance. No severe side effects were observed. Ciprofloxacin at a dose of 100 mg. at night was efficacious in preventing urinary tract infections during 6 months in patients with spinal cord lesions and neurogenic bladder dysfunction. After the controlled study 10 of the 21 patients used ciprofloxacin as prophylaxis for up to 39 months with a marked reduction in the pre-study infection frequency. In 1 patient ciprofloxacin resistant Escherichia coli was subsequently found in the feces.

[Effectiveness and tolerance of cefixime in bacterial urinary tract infections in patients with myelomeningocele]

28 myelomeningocele patients (aged 2-30 years) with clinical symptoms of acute UTI participated in this open uncontrolled clinical trial at the Orthopedic University Hospital of Heidelberg (Dir.: Prof. Dr. H. Cotta). 4 patients were treated with 200 mg cefixime tablets bid, 24 patients received 4 mg/kg body weight cefixime suspension bid, according to age and weight of the patients. The duration of treatment was 6-10 days. Clinical and microbiological examinations were carried out before therapy as well as 1 day and 5 to 9 days after the end of treatment. The data of 25 patients could be evaluated for bacteriological and clinical efficacy. 5-9 days after treatment in 22 patients (88%) complete recovery was stated. In 3 patients a reinfection occurred. In 24 patients (96%) the baseline pathogens were eliminated under cefixime therapy. 5-9 days after the end of treatment in 3 patients reinfection was observed. Clinical side effects could be detected in 1 patient (vomiting). These results indicate that the oral cephalosporin cefixime is efficient and well tolerated in complicated UTI of myelomeningocele patients.

[Laboratory and clinical studies on S-1108 in the pediatric field]

Laboratory and Clinical Studies on S-1108, a new oral cephem antibiotic, were carried out to evaluate its usefulness at a dose between 2 and 4 mg/kg a day for 7 to 14 days in the pediatric field. 1) Pharmacokinetic studies S-1108 at a dose of 2 mg/kg was administered to evaluate the pharmacokinetic parameters in 1 subject. Cmax, T1/2 and AUC were 0.69 hour, 1.42 hours and 2.15 micrograms.hr/ml, respectively. 2) Antimicrobial activities MICs against various clinically isolated organisms (Staphylococcus aureus, Streptococcus pyogenes, Streptococcus pneumoniae, Branhamella catarrhalis, Escherichia coli and Haemophilus influenzae) were determined. The MIC values of S-1006 were similar to those of cefteram, the MICs against S. pyogenes, and H. influenzae were < or = 0.025 and 0.10 microgram/ml, respectively. 3) Clinical studies S-1108 was administered to patients with various pediatrics infections in 34 cases (upper respiratory tract infections: 12 cases, lower respiratory tract infections: 5 cases, urinary tract infections: 9 cases, skin and soft tissue infection: 6 cases, otitis media: 2 cases). Clinical efficacy rate was evaluated according to "Standard of clinical evaluation in pediatrics field". The responses were all good or excellent. 4) Side reactions There were no serious adverse reactions in any cases. The above results suggest that S-1108 is potent effective and safe agent in the pediatric field at a dose between 2-4 mg/kg (t.i.d.) a day.

Blood group antigen expression on vaginal and buccal epithelial cells and mucus in secretor and nonsecretor women

Blood group antigens on epithelial cells may influence bacterial adherence to mucosal surfaces. In the urinary tract the presence of these genetically determined carbohydrate structures may affect bacterial colonization of the vaginal mucosa and subsequent urinary tract infection. In previous studies the detection of ABH and Lewis antigen expression and distribution in tissues have made use of semiquantitative immunohistochemical staining techniques. To determine the pattern and intensity of blood group antigens on epithelial cells and in the mucus overlying them, we developed quantitative immunoassays that use monoclonal antibodies to detect changes in the expression and intensity of ABH and Lewis antigens on cells and in mucus. Vaginal and buccal cell specimens from 23 healthy women (15 secretors and 8 nonsecretors) with no history of urinary tract infections and known blood group types were analyzed for the expression of these antigenic determinants. The profile of ABH antigen expression was generally consistent with the ABO phenotype of the individual and appeared to be influenced by the secretor status; the levels of A, B and H determinants were higher for secretors than nonsecretors. Lewis antigens were detected on vaginal and buccal cells, and mucus. Le(a) and Le(x) antigen expression was greater on cells and mucus from nonsecretors, whereas the expression of Le(b) and Le(y) was greater on cells and mucus from secretors. Variability in antigen expression was observed among individuals with the same blood type and secretor status. The patterns of antigen expression were similar for the vaginal and buccal cell, and mucus samples of an individual but the amount of antigen generally differed for the various samples. These findings document the variation of blood group antigen expression on vaginal epithelial cells and mucus, which may have a significant role in susceptibility to urinary tract infections in women.

[Monitoring treatment with amikacin for urinary tract infections]

The studies were aimed at the determining the serum amikacin levels during the treatment of urinary tract infection as an attempt to monitor this treatment. The study involved 51 patients. Amikacin profile following a single dose of 500 mg i.m. was studied in group 1 (n = 7) while the administration of 2 daily doses of 500 mg for 7 days was investigated in group 2 (24 patients with normal renal functioning). Group 3 (10 patients with renal failure) was given the same amikacin doses for 5 days. Amikacin dosage was modified with the own computer program in group 4. Both lower and peak amikacin serum levels in the groups 1, 2 and 3 ranged markedly from subtherapeutical to toxic. Blood urea and creatinine increased significantly in groups 2 and 3. In group 4 amikacin peak level exceeded in therapeutical value only in out patient, and no an increase in blood creatinine or urea was noted during a 5-day therapy.

Clinical relevance of serum amyloid A protein monitoring in urinary tract infections

We have evaluated the clinical relevance of monitoring acute phase proteins in severe urinary tract infection. Body temperature, white blood cell count, erythrocyte sedimentation rate, serum amyloid A protein (SAA), C-reactive protein (CRP), alpha-1-antichymotrypsin (ACT) and alpha-1-acid glycoprotein (AGP) were determined daily in sera from 18 treated patients. Two patterns of response could be identified: responders and non-responders whose therapy had to be changed. Mean values for each acute phase protein were calculated daily in both responders and non-responders. Statistical evaluation of the significance between the means for each protein was also performed on a daily basis and showed P < 0.01 for SAA and CRP on day 3, for ACT on day 5, and for AGP on day 6. SAA and CRP appear to be the most reliable markers for antimicrobial therapy monitoring in patients with urinary tract infections.

Serum granulocyte colony-stimulating factor in patients with repeated infections

We have already reported significant elevation of serum granulocyte colony-stimulating factor (G-CSF) in the acute phase of infection. In this study, we compared the responses to infection between patients with frequently repeated infection (repeaters) and others (non-repeaters). We examined the clinical data and serum G-CSF levels in 48 patients with acute infections. Serum G-CSF levels were significantly lower in repeaters than in non-repeaters (197.7 +/- 370.0 vs. 1014.1 +/- 924.4 pg/ml. P less than 0.001). There were no significant differences in age, serum total protein, or cholinesterase between the groups, but serum albumin was significantly lower in repeaters than in non-repeaters (2.87 +/- 0.5 vs. 3.31 +/- 0.4 g/dl. P less than 0.005). It is suggested that administration of recombinant G-CSF may be useful for patients with repeated infections.

Binding of uropathogenic Escherichia coli R45 to glycolipids extracted from vaginal epithelial cells is dependent on histo-blood group secretor status

Women with a history of recurrent Escherichia coli urinary tract infections (UTIs) are two to three times more likely to be nonsecretors of histo-blood group antigens than are women without such a history. Further, uroepithelial cells from women who are nonsecretors show enhanced adherence of uropathogenic E. coli compared with cells from secretors. To investigate the hypothesis that nonsecretors express unique receptors for uropathogenic E. coli related to their genetic background, we extracted glycosphingolipids (GSLs) from vaginal epithelial cells collected from nonsecretors and secretors and used an assay in which radiolabeled uropathogenic E. coli were bound to these GSLs separated on TLC plates. An E. coli strain (R45) expressing both P and F adhesins, which was isolated from one of these patients' UTIs, was metabolically labeled with 35S for the TLC binding assay. The radiolabeled E. coli R45 bound to two extended globo-series GSLs, sialosyl gal-globoside (SGG) and disialosyl gal-globoside (DSGG), found in the GSL extracts from nonsecretors but not from secretors. The identity of SGG in the nonsecretor GSL extracts was confirmed in radioimmunoassays using an mAb to SGG and in immunofluorescence assays with this mAb and native vaginal epithelial cells. We show that SGG and DSGG are selectively expressed by epithelial cells of nonsecretors, presumably as a result of sialylation of the gal-globoside precursor glycolipid, which in secretors is fucosylated and processed to ABH antigens. The presence of SGG and DSGG may account for the increased binding of E. coli to uroepithelial cells from nonsecretors and for their increased susceptibility to recurrent UTI.

Clinical significance of measurement of serum D-arabinitol levels in candiduria patients

D-Arabinitol, a major candidal metabolite, is reported to be a useful parameter to diagnose disseminated candidiasis. Conventional determination of serum D-arabinitol levels using gas-liquid chromatography is complicated and time-consuming compared with the enzymatic fluorometric assay, newly available in kits. D-Arabinitol concentrations were determined by both enzymatic fluorometric assay kits and gas-liquid chromatography, and a significant correlation (r = 0.943, p less than 0.01) was found between the two methods in 25 sera from 15 patients with candiduria. D-Arabinitol/creatinine ratios were determined using the enzymatic fluorometric assay in 39 candiduria patients (21 febrile and 18 afebrile) and 22 patients without candiduria as the control. The ratios in the febrile patients were significantly greater than those in the afebrile and the nondocumented candidiasis groups. These results suggest that knowledge of the serum D-arabinitol concentration may help to promptly diagnose invasive candidiasis, particularly Candida pyelonephritis. In addition, enzymatic fluorometric assay kits are considered to be advantageous in that they require little time and are simple to use, as compared with gas-liquid chromatography.

Blood group non-secretors have an increased inflammatory response to urinary tract infection

The aim of this study was to assess the possible relationship between secretor state and the inflammatory response to urinary tract infection (UTI). Girls with recurrent UTI were prospectively studied. They included 61 secretor and 23 non-secretor individuals with 604 episodes of recurrent UTI. The response to each UTI episode was measured as the levels of C-reactive protein, erythrocyte sedimentation rate and the body temperature as well as renal concentrating capacity and pyuria. The levels of C-reactive protein, erythrocyte sedimentation rate and the body temperature were significantly higher in non-secretors than in secretors (p less than 0.04). As a consequence, non-secretors had an increased probability of being assigned a diagnosis of acute pyelonephritis rather than asymptomatic bacteriuria (p less than 0.05). The higher inflammatory response in non-secretors was independent of the Gal alpha 1-4Gal beta adhesin expression of the infecting Escherichia coli strains. The increased inflammatory response to UTI in non-secretors might explain the accumulation of these individuals among patients with renal scarring.

The receptor repertoire defines the host range for attaching Escherichia coli strains that recognize globo-A

Escherichia coli strains which colonize the human urinary tract express lectins specific for different members of the globoseries of glycolipids, e.g., globotetraosylceramide and globo-A. This study investigated the importance of globo-A expression for attachment to human uroepithelial cells, colonization of the urinary tract, and severity of urinary tract infection. The expression of receptor-active glycolipids by erythrocytes and epithelial cells was analyzed by thin-layer chromatography and bacterial overlay as well as by bacterial binding to those cells. The epithelial expression of the globo-A receptor was restricted to individuals of blood group A with a positive secretor state. Consequently, globo-A binding E. coli strains attached only to epithelial cells from these individuals. In contrast, globoside-recognizing strains attached in similar numbers to uroepithelial cells regardless of the ABH blood group and secretor state of the donor. The role of host receptor expression for infection with globo-A-specific E. coli was analyzed in 1,473 children with urinary tract infections. All those infected with strains exclusively expressing globo-A-specific adhesins were found to be of blood group A, compared with 45% in the population at large (P less than 0.006). The inflammatory response (fever, C-reactive protein, erythrocyte sedimentation rate) of individuals infected with these strains was lower than that in individuals with infections caused by globoside binding strains. The results demonstrate the importance of fitness between host receptors and bacterial adhesins for infection and suggest that minor receptor epitope differences have profound effects on the disease process.

Serum and urinary immunoglobulin in the rat model of acute urinary tract infection

Total levels of urine and serum immunoglobulin IgM, IgG and IgA, and the E. coli-specific bacterial immunoglobulin response were determined by enzyme-linked immunosorbent assay (ELISA) in a rat model of acute urinary tract infection. High levels of urinary IgM were detected as early as day 3 post infection and then decreased to statistically insignificant levels. Peak levels of IgG occurred in the serum and urine on day 14. Urine and serum IgA levels remained low throughout the study period. The results demonstrate that in the rat model of acute urinary tract infection, IgM appears first in the urine and serum, and rapidly decreases. IgG then appears in the serum and urine followed by a late E. coli-specific immunoglobulin serum and urine response. Also, a non-specific component of the immunoglobulin response was noted in both the serum and urine. In the rat, IgA appears to play little or no role in the urine or in the serum response to the infection.