Serial concentrations of C-reactive protein as an indicator of urinary tract infection in patients with spinal injury

C - reactive protein and urinary tract infection due to Gram-negative bacteria in a pediatric population at a tertiary hospital, Mwanza, Tanzania

Introduction

Gram-negative bacteria are the major cause of urinary tract infections (UTI) in children. There is limited data on UTI systemic response as measured using C-reactive protein (CRP). Here, we report the association of CRP and UTI among children attending the Bugando Medical Centre, Mwanza, Tanzania.

Methods

A cross-sectional study was conducted between May and July 2017. Urine and blood were collected and processed within an hour of collection. Data were analyzed using STATA version 13.

Results

Of 250 enrolled children, 76(30.4%) had significant bacteriuria with 56(22.4%, 95%CI; 11.5–33.3) having gram-negative bacteria infection. There was dual growth of gram-negative bacteria in 3 patients. Escherichia coli (32.2%, 19/59) was the most frequently pathogen detected. A total of 88/250(35.2%) children had positive CRP on qualitative assay. By multinomial logistic regression, positive CRP (RRR=4.02, 95%CI: 2.1–7.7, P<0.001) and age ≤ 2years (RRR=2.4, 95%CI: 1.23–4.73, P<0.01) significantly predicted the presence of significant bacteriuria due to gram-negative enteric bacteria.

Conclusion

C-reactive protein was significantly positive among children with UTI due to gram-negative bacteria and those with fever. In children with age ≤ 2 years, positive CRP indicates UTI due to gram-negative enteric bacteria.

Pelvic Organ Prolapse-Associated Cystitis

Pelvic organ prolapse (POP) and urinary tract infection (UTI) are important problems, estimated to affect around 14 and 40 % of women, respectively, at some point in their lives. Positive urine culture in the presence of symptoms is the cornerstone of diagnosis of UTI and should be performed along with ultrasound assessment of postvoid residual (PVR) in all women presenting with POP and UTI. PVR over 30 mL is an independent risk factor for UTI, although no specific association with POP and UTI has been demonstrated. The use of prophylactic antibiotics remains controversial. The major risk factors for postoperative UTI are postoperative catheterisation, prolonged catheterisation, previous recurrent UTI and an increased urethro-anal distance—suggesting that global pelvic floor dysfunction may play a role.

Prevention of chronic kidney disease in spina bifida

OBJECTIVE

The prevalence of progressive chronic kidney disease (CKD) in children and adults with spina bifida is considerable, rising, and entirely preventable.

REMOVING THE CAUSE

PREVENTION OF SPINA BIFIDA: The best prevention of CKD in spina bifida is prevention of spina bifida itself through strategies that include folate supplementation, ideally before pregnancy.

THE CAUSE OF CKD

Dysfunctional bladder outlet causes febrile Urinary Tract Infections (UTI), even with clean intermittent catheterization (CIC), and subsequent renal scarring. The development of secondary vesicoureteric reflux (VUR) increases the risk of renal scarring and CKD.

FINDING THE IDEAL MARKER FOR MEASUREMENT OF RENAL FUNCTION IN SPINA BIFIDA

Creatinine-based methods are insensitive because of low muscle mass and underdeveloped musculature in the legs. Only Cystatin C-based eGFR can reliably assess global renal function in these patients. However, unilateral renal damage requires nuclear medicine scans, such as (99m)Tc DMSA. (VIDEO)URODYNAMICS STUDIES (UDS): Early treatment is recommended based on UDS with anticholinergics, CIC, and antibiotic prophylaxis when indicated. Overnight catheter drainage, Botox, and eventually augmentation cystoplasty are required for poorly compliant bladders. A continent child or one rendered continent following surgery is at a higher risk of renal damage.

CONCLUSION

A multidisciplinary approach is required to reduce the burden of CKD in patients with spina bifida. The right tools have to be utilized to monitor these patients, particularly if recurrent UTIs occur. Cystatin C eGFR is preferred for monitoring renal damage in these patients, and (99m)Tc DMSA scans have to be used to detect unilateral renal scarring.

Gender-specific differences in the urinary expression of aldosterone, IL-1α and IL-1β

Aims: This pilot investigation examined the possibility of using urine specimens to explore the difference between the expression of several biomarkers based on gender. These biomarkers include several associated with cardiac damage, oxidative stress and inflammation. Materials & methods: Urine specimens were assayed for total protein, aldosterone, high-sensitivity C-reactive protein, myeloperoxidase and IL-1α and -1β using ELISA. Results: We observed significant differences between the sexes for aldosterone and IL-1α and -1β. Conclusion: The presence of gender-based differences in the urinary expression of these biomarkers may be important for establishing normal baseline values in males and females, and may prove to be of value in the development of rapid noninvasive ways to assess inflammatory and oxidative injury during routine urinalysis.

Symptomatic urinary tract infections after surgery for prolapse and/or incontinence

INTRODUCTION AND HYPOTHESIS

The purpose of our study was to estimate the frequency and risk factors for symptomatic urinary tract infection (UTI) after surgery for stress urinary incontinence (SUI) and/or pelvic organ prolapse (POP).

METHODS

Case-control study of 389 consecutive women who underwent surgery for POP and/or SUI. Cases were defined as a symptomatic, culture-confirmed UTI within 6 weeks of surgery. Multivariable logistic regression was used to determine independent risk factors.

RESULTS

Thirty five (9%) women developed a UTI. The risk of UTI was significantly increased by previous history of multiple UTIs (adjusted OR: 3.7, CI 1.4-10.1), increased distance between the urethra and the anus (adjusted OR: 1.4, CI 1.1-1.9), and prolonged duration of catheterization (adjusted odds ratio (OR) for >or=10 days: 4.2, 95% CI 1.5-11.6); 94.6% of catheterizing women were prescribed daily nitrofurantoin.

CONCLUSIONS

UTI is an important postoperative morbidity after urogynecologic surgery and is common in catheterizing women despite antibiotic prophylaxis.

Chronic inflammation and bladder cancer

The relation between Schistosomiasis and bladder cancer is well-established and accounts for the high rates of bladder cancer in a number of developing countries, including Egypt. In developed countries, transitional cell carcinoma is the predominant type of bladder cancer, whereas in Schistosomiasis-endemic regions, squamous cell carcinoma is the most common type. In this review, experimental and observational data on infection, inflammation, and bladder cancer are summarized with special emphasis on transitional cell carcinoma. Findings from numerous studies suggest that inflammation is likely to have an important role in bladder carcinogenesis in developed countries. Future studies need to focus in greater detail on risk factors that increase inflammation of the bladder, examine genetic susceptibility to inflammatory pathways, and include markers of inflammation measured prior to cancer diagnosis. Understanding the role of inflammation on transitional cell carcinogenesis may provide important insights on how to prevent the sixth most common cancer in the United States.

Fitness, inflammation, and the metabolic syndrome in men with paraplegia

OBJECTIVE

To determine the relations among peak aerobic capacity, physical activity, functional ability, components of the metabolic syndrome (high-density lipoprotein cholesterol [HDL-C], triglycerides [TG], glucose, insulin, abdominal obesity, high blood pressure), and inflammatory factors (interleukin-6 [IL-6], C-reactive protein [CRP]) in men with paraplegia.

DESIGN

Cross-sectional exploratory design.

SETTING

University research laboratory.

PARTICIPANTS

Twenty-two men (age, 39+/-9y; duration of injury, 17+/-9y; level of injury, T2-L2) with functionally complete paraplegia volunteered to participate.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Peak aerobic capacity was measured using a graded peak exercise test with an arm ergometer, and physical activity was assessed by the Physical Activity and Disability Scale. Functional ability was assessed by the Self-Report Functional Measure. Circulating glucose, insulin, HDL-C, TG, total cholesterol, IL-6, and CRP levels were determined by specific enzyme or immunologic assays. Body fat was determined by dual-energy x-ray absorptiometry, and central obesity was estimated from abdominal sagittal diameters.

RESULTS

Lower peak aerobic capacities were associated with lower HDL-C and lower physical activity levels ( P <.014). Lower physical activity levels were associated with higher fasting glucose, lower HDL-C level, and larger abdominal sagittal diameters ( P <.036). Larger abdominal sagittal diameters were associated with higher fasting glucose, higher fasting and postload insulin, lower HDL-C, higher TG, and higher CRP levels ( P <.05).

CONCLUSIONS

Diet and exercise trials are needed to determine the efficacy and effectiveness of lifestyle interventions aimed at slowing the progression of the metabolic syndrome in people with spinal cord injury.

Complications of intermittent catheterization: their prevention and treatment

STUDY DESIGN

Literature review to evaluate the complications seen in patients on intermittent catheterization (IC) and intermittent self-catheterization (ISC).

OBJECTIVES

To find the prevalence of most complications seen in patients on IC. To study the prevention and the treatment of these complications.

SETTING

An international literature review.

METHODS

Most relevant articles on the subject are reviewed.

CONCLUSION

Urinary tract infection is the most frequent complication in patients performing IC. Catheterization frequency and the avoidance of bladder overfilling are amongst the most important prevention measures. Asymptomatic bacteriuria does not need to be treated with antibiotics. Long-term antibacterial prevention does seem to bear a risk of development of bacterial resistance. Previous treatment with indwelling catheters is a risk factor for chronic infection and urinary sepsis. Prostatitis is more frequently present than often thought. Epididymitis and urethritis are rare. Trauma from catheterization occurs regularly, but lasting effects are more limited. However, the prevalence of urethral strictures and false passages increases with longer use of IC. The use of hydrophilic catheters might be able to lower the urethral complication rate but additional proof through comparative studies is needed. The most important prevention measures are good education of all involved in IC, good patient compliance, the use of a proper material and the application of a good catheterization technique.

ACP Best Practice No 167: the laboratory diagnosis of urinary tract infection

Urinary tract infection is common, and it is not surprising that urine specimens make up a large proportion of those samples submitted to the routine diagnostic laboratory. Many of these specimens will show no evidence of infection and several methods can be used to screen out negative samples. Those that grow bacteria need to be carefully assessed to quantify the degree of bacteriuria and hence clinical relevance. To influence treatment, a final report should be produced within 24 hours of specimen receipt, with turnaround times continuously monitored. Much work needs to be done to determine the cost effectiveness involved in processing urine specimens and the evidence base for the final report provided.

Complications of urinary tract infections associated with devices used for long-term bladder management

The long-term indwelling urethral catheter continues to be a major cause of morbidity in patients in hospitals, nursing homes and home care. Many authorities have recommended that wherever possible, alternative techniques should be considered for the management of patients with urinary retention or incontinence. This article considers the complications that develop from the urinary tract infections associated with long-term indwelling catheterization and reviews the evidence that the other options for bladder management pose less serious threats to health.

Virulence factors in Escherichia coli from urinary tract infections in patients with spinal injuries

A collection of 70 strains of Escherichia coli from urinary tract infections in spine-injured patients undergoing long-term bladder catheterization were tested for characteristics that have been associated with the ability to produce pyelonephritis. The incidence of the virulence factors were: mannose-resistant haemagglutinins (30%), P-fimbriae (17%), haemolysin (27%), K-antigens (28%) and aerobactin (by bioassay 33%, by gene probe 39%). Only 54% of the strains belonged to the O-serotypes usually associated with urinary tract infections. E. coli carrying the full complement of virulence factors were rare in the urinary tract of the spinal patients and were not associated with episodes of symptomatic pyelonephritis. It is clear that the neuropathic bladder and the presence of the catheter permits a wide variety of bacterial types to colonize the urinary tract and cause infection of the kidney. The identification of host markers rather than bacterial factors is suggested as a more fruitful approach to the early detection of cases likely to progress to pyelonephritis in this group of patients.

N-nitrosamine generation by urinary tract infections in spine injured patients

Urine was collected from 33 patients resident at the Welsh Spinal Injuries Unit and analysed for volatile N-nitrosamines by gas chromatography. N-nitrosodime-thylamine, N-nitrosopiperidine or N-nitrosopyrrolidine was detected in 32 of the samples. Thirty-one of the samples were infected by one or more microbial species. Nitrate and N-nitrosamines were not found in the sterile urines of a group of 10 control individuals exposed to the same dietary and environmental influences as the spinal patients. Although N-nitrosamines were found in some of the catheter drainage system products, they did not elute into urine on 24-h exposure. In addition, 6 of the nitrosamine-containing urines had no contact with drainage systems as they were collected from spinal patients who were capable of independent voiding. It was concluded that the nitrosamines detected in the urines arose from the bacterial nitrosation of urinary amines. These results support the hypothesis that chronic urinary tract infection may have a role in the aetiology of bladder cancer in spine injured patients.

C-reactive protein as a diagnostic test of sepsis in the critically ill

Changes in the plasma concentration of C-reactive protein were assessed as a diagnostic test for sepsis in critically ill patients. Forty-nine episodes of secondary sepsis were identified in 31 patients. In 43 out of the 49 episodes there was a 25% or greater change in the concentration of C-reactive protein on the day that sepsis was diagnosed but in six episodes of sepsis the change was less than 25%. A 25% rise in the plasma concentration of C-reactive protein in the absence of other non-infective causes of a raised C-reactive protein, such as inflammation, tissue injury or surgery, is highly suggestive of infection, but failure of the C-reactive protein to rise does not eliminate a diagnosis of sepsis.

C-reactive protein: a critical review

We have reviewed the literature to determine the value of C-reactive protein (CRP) measurements in the diagnosis and management of a wide range of conditions. CRP levels are of value in 6 clinical situations: (a) monitoring the response to antibiotic treatment in patients with known bacterial infections, (b) in obstetric patients with premature rupture of membranes, a rise in CRP can give early warning of intrauterine infections, (c) differentiation between active disease and infections in patients with systemic lupus and ulcerative colitis where the level of response to active disease has been previously established, (d) as a measure of disease activity and response to disease-modifying drugs in rheumatoid arthritis, (e) early detection of complications in postoperative patients, (f) in differentiating between infection and graft-versus-host-disease in bone marrow transplant patients. CRP levels have been used in an attempt to differentiate between bacterial and viral infections in various clinical situations, however the published literature does not support this role.

Antibody coated bacteria in urine of patients with recent spinal injury

Twenty patients with an acute spinal injury were prospectively studied to assess the clinical importance of antibody coated bacteria (ACB) in the urine and the association among the different bacterial species with a positive antibody coated bacteria test. Clinical urinary tract infection was associated with a positive ACB test on 45% of occasions. Three hundred and ninety nine urine samples containing 541 bacterial isolates were assessed for the presence of ACB; 13% were found to be positive and 87% negative for ACB; 67% of urines contained a single bacterial isolate. Pseudomonas aeruginosa was most commonly associated with clinical urinary tract infection, found in 25% of episodes, followed by Proteus mirabilis (17.5%), Klebsiella sp (12.5%), and Proteus morganii (10%). Providencia stuartii, however, was most commonly associated with a positive ACB test (found in 17%). Other bacteria associated with a positive ACB test included Klebsiella sp (14%), Acinetobacter sp (12.5%), Pseudomonas aeruginosa (12%), Citrobacter sp (11.5%). A positive ACB test is not to be expected from a patient with spinal injury who has a catheter in place, and the test may provide a useful guide to identify those patients with an invasive infection. It is doubtful that a decision to treat or not treat bacteriuria could rest on the identification of the bacterial species alone.

An appraisal of antibiotic policies for urinary tract infections in patients with spinal cord injuries undergoing long-term intermittent catheterisation

The antibiotic policies that have been recommended in the literature for the prevention and treatment of urinary tract infections in patients with spinal cord injuries undergoing long-term intermittent catheterisation are reviewed. Current practices in spinal units in England and Wales are reported and the rational bases of these policies are considered.