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Chai TC, Wolfe AJ, Brubaker L. The Urinary Microbiome: Improving Diagnostics and Management of Urinary Tract Infections in Adult Females. Infect Dis Clin North Am 2024; 38:241-253. [PMID: 38729665 DOI: 10.1016/j.idc.2024.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/12/2024]
Abstract
This article discusses the urinary microbiome in relation to urinary tract infection (UTI) in women. It makes biologic sense that the microbiota of different niches (bladder, vagina, and gut) interact with each other in health, as well as during a UTI event; however, these relationships remain poorly understood. Future research should close knowledge gaps regarding the interactions between the urinary microbiota and the host, amongst the microbiota of adjacent niches, and between the microbes within the same microbiota. The new knowledge should result in improved UTI treatment in the age of antibiotic stewardship.
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Affiliation(s)
- Toby C Chai
- Department of Urology, Boston University Chobanian & Avedisian School of Medicine and Boston Medical Center, 725 Albany Street, Suite 3B, Boston, MA 02118, USA.
| | - Alan J Wolfe
- Department of Microbiology and Immunology, Stritch School of Medicine, Loyola University Chicago, 2160 South First Avenue, Building 115, Room 215, Maywood, IL 60153, USA
| | - Linda Brubaker
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Division of Urogynecology and Reconstructive Pelvic Surgery, University of California, 9300 Campus Point, Mail Code 7433, La Jolla, CA 92037-7433, USA
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Zhang Y, Chen C, Mitsnefes M, Huang B, Devarajan P. Evaluation of diagnostic accuracy of urine neutrophil gelatinase-associated lipocalin in patients with symptoms of urinary tract infections: a meta-analysis. Front Pediatr 2024; 12:1368583. [PMID: 38840804 PMCID: PMC11150804 DOI: 10.3389/fped.2024.1368583] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Accepted: 04/23/2024] [Indexed: 06/07/2024] Open
Abstract
Introduction Early and accurate diagnosis of urinary tract infection (UTI) can prevent serious sequelae including chronic kidney disease. Multiple individual studies have identified urine neutrophil gelatinase-associated lipocalin (uNGAL) as a promising biomarker for early diagnosis of UTI. We sought to understand the distribution and diagnostic accuracy of uNGAL values in patients presenting with UTI symptoms. Methods Our systematic literature reviews in PubMed, Embase, and Cochrane Reviews up to March 2024, identified 25 studies reporting mean/median, standard deviation/quartiles, and detection limits of uNGAL in symptomatic patients with and without culture-confirmed UTI. Seventeen studies were in children. Meta-analyses were performed using the quantile estimation (QE) method estimating the distributions of uNGAL, which were then compared between the UTI and non-UTI groups for identifying the best cut-off points maximizing the Youden index. Sensitivity analyses were performed on all 25 studies including adult patients. Results We found that uNGAL levels were significantly higher in samples with confirmed UTI compared to those without. In pediatric studies, median and 95% confidence interval (CI) of uNGAL values were 22.41 (95% CI of 9.94, 50.54) ng/mL in non-UTI group vs. 118.85 (95% CI of 43.07, 327.97) ng/mL in UTI group. We estimated the cut-off point of 48.43 ng/mL with highest sensitivity (96%) and specificity (97%) in children. Sensitivity analysis including both pediatric and adult studies yielded similar results. Discussion The level of uNGAL in symptomatic patients with confirmed UTI is much higher than that reported in patients without UTI. It may be used as a diagnostic tool to identify UTI early among symptomatic patients. The range of uNGAL concentrations and cut-off points reported in subjects with UTI is much lower than that reported in patients with acute intrinsic kidney injury. Systematic Review Registration https://www.crd.york.ac.uk/, PROSPERO (CRD42023370451).
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Affiliation(s)
- Yin Zhang
- Division of Biostatistics and Epidemiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, United States
| | - Chen Chen
- Division of Biostatistics and Epidemiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, United States
| | - Mark Mitsnefes
- Division of Nephrology and Hypertension, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, United States
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, United States
| | - Bin Huang
- Division of Biostatistics and Epidemiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, United States
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, United States
| | - Prasad Devarajan
- Division of Nephrology and Hypertension, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, United States
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, United States
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Omic H, Eder M. Effect of increasing age and ureteral stent implantation on urinary tract infections after kidney transplantation - update of recent literature. Curr Opin Urol 2024; 34:146-153. [PMID: 38426237 PMCID: PMC10990026 DOI: 10.1097/mou.0000000000001163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/02/2024]
Abstract
PURPOSE OF REVIEW This review aims to present the recent literature regarding effects of aging and ureteral stent implantation (UrS) on the risk of urinary tract infections (UTIs) in kidney transplant (KTX) recipients. RECENT FINDINGS UTIs in kidney transplant recipients remain a clinical challenge and represent a leading cause of morbidity, hospitalization rates, and mortality. Higher age was described as a significant risk factor for UTIs in several studies including a recent Brazilian analysis, indicating a 3.6%/years of age increase in UTI risk. Subsequently, a large meta-analysis, published in 2023, confirmed the correlation between older age and elevated UTI risk. The Swiss Transplant Cohort Study in 2022, largest of its kind, similarly confirmed a link between advanced age and heightened risk of recurrent UTIs in KTX. A recent prospective study highlighted UrS placement as a modifiable risk factor, emphasizing the need for careful consideration and antibiotic prophylaxis. Additionally, the type of stents played a crucial role, with external stents associated with a 1.69 times higher UTI risk. The challenge of determining optimal UrS removal timing further complicates posttransplant care, with insufficient evidence to guide practices. SUMMARY The aging population of KTX recipients requires a personalized approach to effectively reduce and manage UTIs as one of the most important complications following KTX. Prophylactic stent implantation is successful in lowering ureteral complications, however, is associated with an increased incidence of UTIs. To reduce the increased risk of UTIs, the length of stent insertion requires strict supervision and maintenance.
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Affiliation(s)
- Haris Omic
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Vienna, Austria
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Akhlaghpour M, Haley E, Parnell L, Luke N, Mathur M, Festa RA, Percaccio M, Magallon J, Remedios-Chan M, Rosas A, Wang J, Jiang Y, Anderson L, Baunoch D. Urine biomarkers individually and as a consensus model show high sensitivity and specificity for detecting UTIs. BMC Infect Dis 2024; 24:153. [PMID: 38297221 PMCID: PMC10829179 DOI: 10.1186/s12879-024-09044-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Accepted: 01/22/2024] [Indexed: 02/02/2024] Open
Abstract
BACKGROUND Current diagnoses of urinary tract infection (UTI) by standard urine culture (SUC) has significant limitations in sensitivity, especially for fastidious organisms, and the ability to identify organisms in polymicrobial infections. The significant rate of both SUC "negative" or "mixed flora/contamination" results in UTI cases and the high prevalence of asymptomatic bacteriuria indicate the need for an accurate diagnostic test to help identify true UTI cases. This study aimed to determine if infection-associated urinary biomarkers can differentiate definitive UTI cases from non-UTI controls. METHODS Midstream clean-catch voided urine samples were collected from asymptomatic volunteers and symptomatic subjects ≥ 60 years old diagnosed with a UTI in a urology specialty setting. Microbial identification and density were assessed using a multiplex PCR/pooled antibiotic susceptibility test (M-PCR/P-AST) and SUC. Three biomarkers [neutrophil gelatinase-associated lipocalin (NGAL), and Interleukins 8 and 1β (IL-8, and IL-1β)] were also measured via enzyme-linked immunosorbent assay (ELISA). Definitive UTI cases were defined as symptomatic subjects with a UTI diagnosis and positive microorganism detection by SUC and M-PCR, while definitive non-UTI cases were defined as asymptomatic volunteers. RESULTS We observed a strong positive correlation (R2 > 0.90; p < 0.0001) between microbial density and the biomarkers NGAL, IL-8, and IL-1β for symptomatic subjects. Biomarker consensus criteria of two or more positive biomarkers had sensitivity 84.0%, specificity 91.2%, positive predictive value 93.7%, negative predictive value 78.8%, accuracy 86.9%, positive likelihood ratio of 9.58, and negative likelihood ratio of 0.17 in differentiating definitive UTI from non-UTI cases, regardless of non-zero microbial density. NGAL, IL-8, and IL-1β showed a significant elevation in symptomatic cases with positive microbe identification compared to asymptomatic cases with or without microbe identification. Biomarker consensus exhibited high accuracy in distinguishing UTI from non-UTI cases. CONCLUSION We demonstrated that positive infection-associated urinary biomarkers NGAL, IL-8, and IL-1β, in symptomatic subjects with positive SUC and/or M-PCR results was associated with definitive UTI cases. A consensus criterion with ≥ 2 of the biomarkers meeting the positivity thresholds showed a good balance of sensitivity (84.0%), specificity (91.2%), and accuracy (86.9%). Therefore, this biomarker consensus is an excellent supportive diagnostic tool for resolving the presence of active UTI, particularly if SUC and M-PCR results disagree.
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Affiliation(s)
- Marzieh Akhlaghpour
- Department of Research and Development, Pathnostics, 15545 Sand Canyon Suite 100, Irvine, CA, 92618, USA
| | - Emery Haley
- Department of Clinical Research, Pathnostics, 15545 Sand Canyon Suite 100, Irvine, CA, 92618, USA
| | - Laura Parnell
- Department of Scientific Writing, Precision Consulting, 6522 Harbor Mist, Missouri City, TX, 77459, USA
| | - Natalie Luke
- Department of Clinical Research, Pathnostics, 15545 Sand Canyon Suite 100, Irvine, CA, 92618, USA
| | - Mohit Mathur
- Department of Medical Affairs, Pathnostics, 15545 Sand Canyon Suite 100, Irvine, CA, 92618, USA
| | - Richard A Festa
- Department of Research and Development, Pathnostics, 15545 Sand Canyon Suite 100, Irvine, CA, 92618, USA
| | - Michael Percaccio
- Department of Research and Development, Pathnostics, 15545 Sand Canyon Suite 100, Irvine, CA, 92618, USA
| | - Jesus Magallon
- Department of Research and Development, Pathnostics, 15545 Sand Canyon Suite 100, Irvine, CA, 92618, USA
| | - Mariana Remedios-Chan
- Department of Research and Development, Pathnostics, 15545 Sand Canyon Suite 100, Irvine, CA, 92618, USA
| | - Alain Rosas
- Department of Research and Development, Pathnostics, 15545 Sand Canyon Suite 100, Irvine, CA, 92618, USA
| | - Jimin Wang
- Department of Statistical Analysis, Stat4Ward, 2 Edgemoor Lane, Pittsburgh, PA, 15238, USA
| | - Yan Jiang
- Department of Statistical Analysis, Stat4Ward, 2 Edgemoor Lane, Pittsburgh, PA, 15238, USA
| | - Lori Anderson
- Department of Writing, L. Anderson Diagnostic Market Access Consulting, 2755 Eagle Street, San Diego, CA, 92103, USA
| | - David Baunoch
- Department of Research and Development, Pathnostics, 15545 Sand Canyon Suite 100, Irvine, CA, 92618, USA.
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Haley E, Luke N, Mathur M, Festa RA, Wang J, Jiang Y, Anderson LA, Baunoch D. The Prevalence and Association of Different Uropathogens Detected by M-PCR with Infection-Associated Urine Biomarkers in Urinary Tract Infections. Res Rep Urol 2024; 16:19-29. [PMID: 38221993 PMCID: PMC10787514 DOI: 10.2147/rru.s443361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Accepted: 12/16/2023] [Indexed: 01/16/2024] Open
Abstract
Background Many emerging uropathogens are currently identified by multiplex polymerase chain reaction (M-PCR) in suspected UTI cases. Standard urine culture (SUC) has significantly lower detection rates, raising questions about whether these organisms are associated with UTIs and truly cause inflammation. Objective To determine if microbes detected by M-PCR were likely causative of UTI by measuring inflammatory biomarkers in the urine of symptomatic patients. Design Setting and Participants Midstream voided urine was collected from subjects ≥60 years presenting to urology clinics with symptoms of UTI (n = 1132) between 01/2023 and 05/2023. Microbe detection was by M-PCR and inflammation-associated biomarker (neutrophil gelatinase-associated lipocalin, interleukin 8, and interleukin 1β) was by enzyme-linked immunosorbent assay. Biomarker positivity was measured against individual and groups of organisms, E. coli and non-E. coli cases, emerging uropathogens, monomicrobial and polymicrobial cases. Outcome Measurements and Statistical Analysis Distributions were compared using 2-sample Wilcoxon Rank Sum test with 2-tailed p-values < 0.05 considered statistically significant. Results and Limitations M-PCR was positive in 823 (72.7%) specimens with 28 of 30 (93%) microorganisms/groups detected. Twenty-six of twenty-eight detected microorganisms/groups (93%) had ≥2 biomarkers positive in >66% of cases. Both non-E. coli cases and E. coli cases had significant biomarker positivity (p < 0.05). Limitations were that a few organisms had low prevalence making inferences about their individual significance difficult. Conclusion The majority of microorganisms identified by M-PCR were associated with active inflammation measured by biomarker positivity, indicating they are likely causative of UTIs in symptomatic patients. This includes emerging uropathogens frequently not detected by standard urine culture.
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Affiliation(s)
- Emery Haley
- Department of Clinical Research, Pathnostics, Irvine, CA, USA
| | - Natalie Luke
- Department of Clinical Research, Pathnostics, Irvine, CA, USA
| | - Mohit Mathur
- Department of Medical Affairs, Pathnostics, Irvine, CA, USA
| | - Richard A Festa
- Department of Research and Development, Pathnostics, Irvine, CA, USA
| | - Jimin Wang
- Department of Statistical Analysis, Stat4Ward, Pittsburgh, PA, USA
| | - Yan Jiang
- Department of Statistical Analysis, Stat4Ward, Pittsburgh, PA, USA
| | - Lori A Anderson
- L.Anderson Diagnostic Market Access Consulting, San Diego, CA, USA
| | - David Baunoch
- Department of Research and Development, Pathnostics, Irvine, CA, USA
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Wang D, Haley E, Luke N, Mathur M, Festa RA, Zhao X, Anderson LA, Allison JL, Stebbins KL, Diaz MJ, Baunoch D. Emerging and Fastidious Uropathogens Were Detected by M-PCR with Similar Prevalence and Cell Density in Catheter and Midstream Voided Urine Indicating the Importance of These Microbes in Causing UTIs. Infect Drug Resist 2023; 16:7775-7795. [PMID: 38148772 PMCID: PMC10750486 DOI: 10.2147/idr.s429990] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2023] [Accepted: 11/29/2023] [Indexed: 12/28/2023] Open
Abstract
Introduction This study compared microbial compositions of midstream and catheter urine specimens from patients with suspected complicated urinary tract infections to determine if emerging and fastidious uropathogens are infecting the bladder or are contaminants. Methods Urine was collected by in-and-out catheter (n = 1000) or midstream voiding (n = 1000) from 2000 adult patients (≥60 years of age) at 17 DispatchHealth sites across 11 states. The two groups were matched by age (mean 81 years), sex (62.1% female, 37.9% male), and ICD-10-CM codes. Microbial detection was performed with multiplex polymerase chain reaction (M-PCR) with a threshold for "positive detection" ≥ 10,000 cells/mL for bacteria or any detection for yeast. Results were divided by sex. Results In females, 28 of 30 microorganisms/groups were found by both collection methods, while in males 26 of 30 were found by both. There were significant overlaps in the detection and densities of classical uropathogens including Escherichia coli, Enterococcus faecalis, and Klebsiella pneumoniae, as well as emerging uropathogens including Actinotignum schaalii and Aerococcus urinae. In females, detection rates were slightly higher in midstream voided compared to catheter-collected (p = 0.0005) urine samples, while males showed the opposite trend (p < 0.0001). More polymicrobial infections were detected in midstream voided compared to catheter-collected samples (64.4% vs 45.7%, p < 0.0001) in females but the opposite in males (35.6% vs 47.0%, p = 0.002). Discussion In-and-out catheter-collected and midstream voided urine specimens shared significant similarities in microbial detections by M-PCR, with some differences found for a small subset of organisms and between sexes. Conclusion Non-invasive midstream voided collection of urine specimens for microbial detection and identification in cases of presumed UTI does not result in significantly more contamination compared to in-and-out catheter-collected specimens. Additionally, organisms long regarded as contaminants should be reconsidered as potential uropathogens.
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Affiliation(s)
- Dakun Wang
- Department of Writing, Stat4Ward, Pittsburgh, PA, USA
| | - Emery Haley
- Department of Clinical Research, Pathnostics, Irvine, CA, USA
| | - Natalie Luke
- Department of Clinical Research, Pathnostics, Irvine, CA, USA
| | - Mohit Mathur
- Department of Medical Affairs, Pathnostics, Irvine, CA, USA
| | | | - Xinhua Zhao
- Department of Statistical Analysis, Stat4Ward, Pittsburgh, PA, USA
| | - Lori A Anderson
- L. Anderson Diagnostic Market Access Consulting, San Diego, CA, USA
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Haley E, Luke N, Mathur M, Festa RA, Wang J, Jiang Y, Anderson L, Baunoch D. Comparison Shows that Multiplex Polymerase Chain Reaction Identifies Infection-associated Urinary Biomarker-positive Urinary Tract Infections That Are Missed by Standard Urine Culture. EUR UROL SUPPL 2023; 58:73-81. [PMID: 38152485 PMCID: PMC10751541 DOI: 10.1016/j.euros.2023.10.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/21/2023] [Indexed: 12/29/2023] Open
Abstract
Background Multiplex polymerase chain reaction (M-PCR) has increased sensitivity for microbial detection compared with standard urine culture (SUC) in cases diagnosed as urinary tract infections (UTIs), leading to questions whether detected microbes are likely causative of UTIs or are incidental findings. Objective To compare infection-associated biomarker levels against M-PCR and SUC results in symptomatic cases with a presumptive diagnosis of a UTI by a urologist. Design setting and participants Participants were ≥60 yr old and presented to urology clinics between January and April 2023 with symptoms of UTIs (n = 583). Urine microbial detection was by M-PCR and SUC. Three infection-associated biomarkers (neutrophil gelatinase-associated lipocalin, interleukin-8, and interleukin-1β) were measured by enzyme-linked immunosorbent assay. Symptomatic cases with elevated biomarkers, detection of uropathogens, and a specialist clinical diagnosis of a UTI were considered definitive UTI cases. Outcome measurements and statistical analysis Distributions were compared using two-sample Wilcoxon rank sum test, with two-tailed p values of <0.05 considered statistically significant. Results and limitations In cases with M-PCR-positive/SUC-negative results (n = 80), all median biomarker levels were significantly higher (p < 0.0001) than in cases with M-PCR-negative/SUC-negative results (n = 107). Two or more biomarkers were positive in 76% of M-PCR-positive/SUC-negative specimens. Limitation was an inability to examine associations between each individual organism and inflammation. Conclusions A significant number of M-PCR-positive/SUC-negative cases had elevated levels of infection-related urinary biomarkers, especially when infection was caused by organisms other than Escherichia coli. This is a strong indication that microbes detected by M-PCR, which would be missed by SUC, are associated with UTIs. Patient summary We compared infection-associated biomarkers in patients diagnosed with urinary tract infections (UTIs) against the detection of microorganisms by standard urine culture (SUC) and multiplex polymerase chain reaction (M-PCR). We found that most patients with microorganisms detected by M-PCR, which were missed by SUC, had elevated markers of inflammation, indicating that these organisms were likely causative of UTIs.
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Affiliation(s)
- Emery Haley
- Department of Clinical Research, Pathnostics, Irvine, CA, USA
| | - Natalie Luke
- Department of Clinical Research, Pathnostics, Irvine, CA, USA
| | - Mohit Mathur
- Department of Medical Affairs, Pathnostics, Irvine, CA, USA
| | - Richard A. Festa
- Department of Research and Development, Pathnostics, Irvine, CA, USA
| | - Jimin Wang
- Department of Statistical Analysis, Stat4Ward, Pittsburgh, PA, USA
| | - Yan Jiang
- Department of Statistical Analysis, Stat4Ward, Pittsburgh, PA, USA
| | - Lori Anderson
- L. Anderson Diagnostic Market Access Consulting, San Diego, CA, USA
| | - David Baunoch
- Department of Research and Development, Pathnostics, Irvine, CA, USA
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