Approach to a patient with urosepsis

Market-ready U-AST kit: simple, fast, cost-effective solution for concurrently detecting urinary tract infection and antibiotic resistance

There is an increasing demand for an inexpensive, quick, accessible, and simple method for the detection of urinary tract infection (UTI) together with the antibiotic-resistance profile of the infection-causing bacteria. Our primary goal is to assist doctors in prescribing antibiotics that will quickly treat infections and reduce the likelihood of antibiotic resistance spreading throughout the community. To this end, a urinary tract infection antibiotic-sensitivity test (U-AST) kit was developed for the validation of bacterial infection in the urinary tract and determination of the antibiotic-resistance profile of the bacteria in a short time. The U-AST kit was standardized using standard strains of bacteria, specifically Escherichia coli, Enterococcus faecalis, Pseudomonas aeruginosa, Vibrio cholerae, and Pseudomonas species. Further, the kit was validated using 50 clinical urine samples with variation in their physical and chemical parameters, and the resistance pattern against five therapeutically important antibiotics were tested. The results acquired using the U-AST kit showed a 100% similarity to those acquired using the laboratory-based gold standard method. Interestingly, the U-AST kit required a maximum of 9 h to understand the bacterial contamination and resistance profile of the bacterial community, which was observed by a simple color change. The same result can be obtained using the gold standard method but requires 36-72 h, a sophisticated microbiology method, and skilled microbiologists. Other methods can also predict infection quickly with the aid of sophisticated instrumentation; however, understanding the antibiotic-resistance pattern is not possible. To the best of our understanding, this is a unique technique for the quick, easy, and inexpensive detection of UTI with antibiotic sensitivity testing and does not require a special laboratory set-up or expert personnel. The commercialization of the developed clinically validated U-AST kit is currently underway.

Phage vB_Ec_ZCEC14 to treat antibiotic-resistant Escherichia coli isolated from urinary tract infections

Escherichia coli is a commensal bacterial species in the human gastrointestinal tract; however, it could be pathogenic and cause severe infections in intra and extra-intestinal sites. Uropathogenic E. coli accounts for 80-90% of urinary tract infections that can result in urosepsis and septic shock. Consequently, multidrug-resistant uropathogenic E. coli poses a considerable risk to the healthcare system worldwide. Phage therapy is demonstrated as an optimistic solution to over-the-counter antibiotics that contribute to the global issue of multidrug-resistant bacteria. This study aims to isolate a novel phage that could be implemented to cure urinary tract infections mediated by multidrug-resistant E. coli. Twenty-seven E. coli isolates were collected from patients with urinary tract infections to assess the antibacterial efficacy of phage vB_Ec_ZCEC14. Phage kinetics were encountered against the E. coli strain (EC/4), in addition to evaluating phage stability under various temperatures, pH values, and UV exposure periods. Full genome sequencing and morphological analysis were conducted for further phage characterization, which revealed that phage vB_Ec_ZCEC14 belongs to the family Straboviridae. Phage vB_Ec_ZCEC14 showed thermal tolerance at 80 ℃, pH stability between pH 3 and pH 12, and endurance to UV exposure for 45 min. The phage-host interaction results revealed that phage vB_Ec_ZCEC14 has strong and steady antibacterial action at lower concentrations (MOI 0.1). The study findings strongly indicate that phage vB_Ec_ZCEC14 holds significant promise as a potential therapeutic alternative for treatment of antibiotic-resistant uropathogenic E. coli.

Validation of quantitative loop-mediated isothermal amplification assay using a fluorescent distance-based paper device for detection of Escherichia coli in urine

Uropathogenic Escherichia coli (UPEC) causes up to 90% of urinary tract infections (UTI) which is more prevalent among females than males. In urine, patients with symptomatic UTI usually have a high concentration of bacterial infection, ≥ 105 colony-forming units (CFU) per mL, in which the culture method is regularly the gold standard diagnosis. In this study, a simple and inexpensive distance-based paper device (dPAD) combined with the fluorescent closed tube LAMP assay was validated for simultaneously screening and semi-quantifying the infection level of E. coli in 440 urine samples of patients with UTI. The dPAD could measure the LAMP amplicons and semi-quantify the levels of E. coli infection in heavy (≥ 104 CFU/mL), light (≤ 103 CFU/mL) and no infection. The sensitivity and specificity had reliable performances, achieving as high as 100 and 92.7%, respectively. The one step LAMP assay could be performed within 3 h, which was 7.5 times faster than the culture method. To empower early UTI diagnosis and fast treatment, this inexpensive dPAD tool combined with the fluorescent closed tube LAMP assay is simple, reliably fast and practically portable for point-of-care settings, particularly in resource-limited areas, which can be set up in all levels of healthcare facilities.

Exploring the Dynamic Role of Bacterial Etiology in Complicated Urinary Tract Infections

Background and Objectives. Numerous studies have been conducted to explore the epidemiological characteristics of urinary tract infections (UTI) and sepsis. However, there is still a lack of relevant bacteriological features and prognostic information regarding urosepsis based on bacteriological etiology. The current study aims to evaluate the bacterial etiology of complicated UTI (cUTI) and bacterial resistance to antibiotics and whether they present an intrinsic risk of developing urosepsis. Materials and Methods. A retrospective study was performed that included 102 patients who were diagnosed with cUTI and admitted to the urology department of the "Sfântul Apostol Andrei" County Emergency Clinical Hospital (GCH) from September 2019 to May 2022. Results. A considerable number of patients, n = 41 (40.2%), were diagnosed with multi drug-resistant (MDR) infection. Escherichia coli (E. coli) was identified as the prevailing pathogen, accounting for 51 patients. Klebsiella manifested itself as the subsequent causative agent in 27 instances. The presence of Enterococcus spp. infection was documented in 13 patients, whereas Pseudomonas emerged as the etiological perpetrator in the clinical context of 8 patients. The current study found a substantial prevalence of resistance to first-line antibiotics. The overall resistance rate was 74.5% for penicillin, 58.82% for trimethoprim-sulfamethoxazole and 49% for fluoroquinolones; cephalosporin resistance displayed an inverse correlation with antibiotic generation with fourth-generation cephalosporins exhibiting a resistance rate of 24.5%, and first-generation cephalosporins demonstrating a resistance rate of 35.29%. Conclusions. Age, comorbidities and indwelling urinary catheters are risk factors for developing MDR infections. While the intrinsic characteristics of the causative bacterial agent in cUTI may not be a risk factor for developing urosepsis, they can contribute to increased mortality risk. For empiric antibiotic treatment in patients with cUTI who are at a high risk of developing urosepsis and experiencing a potentially unfavorable clinical course, broad-spectrum antibiotic therapy is recommended. This may include antibiotics, such as amikacin, tigecycline, carbapenems and piperacillin-tazobactam.

Acute physiology and chronic health evaluation score and mortality of patients admitted to intermediate care units of a hospital in a low- and middle-income country: A cross-sectional study from Pakistan

Background

Intermediate care units (IMCUs) serve as a bridge between general wards and intensive care units by providing close monitoring and rapid response to medical emergencies. We aim to identify the common acute medical conditions in patients admitted to IMCU and compare the predicted mortality of these conditions by acute physiology and chronic health evaluation-II (APACHE-II) score with actual mortality.

Methods

A cross-sectional study was conducted at a tertiary care hospital from 2017 to 2019. All adult internal medicine patients admitted to IMCUs were included. Acute conditions were defined as those of short duration (<3 weeks) that require hospitalization. The APACHE-II score was used to determine the severity of these patients' illnesses.

Results

Mean (standard deviation [SD]) age was 62 (16.5) years, and 493 (49.2%) patients were male. The top three acute medical conditions were acute and chronic kidney disease in 399 (39.8%), pneumonia in 303 (30.2%), and urinary tract infections (UTIs) in 211 (21.1%). The mean (SD) APACHE-II score of these patients was 12.5 (5.4). The highest mean APACHE-II (SD) score was for acute kidney injury (14.7 ± 4.8), followed by sepsis/septic shock (13.6 ± 5.1) and UTI (13.4 ± 5.1). Sepsis/septic shock was associated with the greatest mortality (odds ratio [OR]: 6.9 [95% CI (confidence interval): 4.5-10.6]), followed by stroke (OR: 3.9 [95% CI: 1.9-8.3]) and pneumonia (OR: 3.0 [95% CI: 2.0-4.5]).

Conclusions

Sepsis/septic shock, stroke, and pneumonia are the leading causes of death in our IMCUs. The APACHE-II score predicted mortality for most acute medical conditions but underestimated the risk for sepsis and stroke.

Determinants of urinary tract infection in hospitalized patients with acute ischemic stroke

BACKGROUND

Stroke is a major cause of morbidity and mortality worldwide. Urinary tract infection (UTI) is a common post-acute ischemic stroke (AIS) complication. We assessed the incidence, determinant factors, infection characteristics, post-stroke complications, and outcomes of hospitalized AIS patients with UTI.

METHODS

This retrospective cohort study included AIS patients admitted within 7 days of stroke onset. The patients were divided into the UTI group and the non-UTI (control) group. Clinical data were collected and compared between the groups.

RESULTS

There were 342 AIS patients (31 with UTIs and 311 controls). The multivariate analysis showed that an initial National Institutes of Health Stroke Scale (NIHSS) score of ≥ 15 (odds ratio [OR] 5.00, 95% confidence interval [CI] 1.33-18.72) and Foley catheter retention (OR 14.10, 95% CI 3.25-61.28) were risk factors for UTI, whereas smoking (OR 0.08, 95% CI 0.01-0.50), an initial systolic blood pressure (SBP) of > 120 mmHg (OR 0.06, 95% CI 0.01-0.31), and statin use (OR 0.02, 95% CI 0.0006-0.42) were protective factors. Twenty cases (64.5%) were community-acquired and 11 cases (35.3%) were hospital-acquired. Ten patients (32.3%) had catheter-associated UTIs. The most common pathogen was Escherichia coli (13 patients, 41.9%). Post-stroke complications were significantly more common in the UTI group, including pneumonia, respiratory failure, sepsis, brain edema, seizure, symptomatic hemorrhagic transformation, congestive heart failure, atrial fibrillation with a rapid ventricular response, acute kidney injury, and hyponatremia. The median length of stay (LOS) in the UTI group was 12 days versus 3 days in the control group (p < 0.001). The median 3-month modified Rankin Scale score was higher (5 in UTI and 2 in control; p < 0.001) and the median 3-month Barthel Index was lower (0 in UTI and 100 in control; p < 0.001) in the UTI group than in the control group.

CONCLUSIONS

The risk factors for post-AIS UTI included severe stroke (NIHSS score ≥ 15) and urethral catheter indwelling. An initial SBP of > 120 mmHg and statin use were protective factors. The UTI group had significantly worse post-stroke complications, a longer LOS, and worse 3-month outcomes. Smoking was protective, which requires further investigation.

Predictors of Urosepsis Post Percutaneous Nephrolithotomy at King Abdulaziz Medical City, Riyadh

INTRODUCTION

The procedure of percutaneous nephrolithotomy (PCNL) is considered a minimally invasive method for removing stones from the kidneys or ureters. PCNL can cause a wide range of complications, such as urosepsis, a rare but serious complication.

METHODS

A retrospective cohort study of patients who underwent PCNL from the period 2016 to 2022 was conducted at King Abdulaziz Medical City. Data were collected by chart review using the BestCARE system. SPSS version 23 (IBM Corporation, Armonk, NY, USA) was used. Qualitative variables were expressed as percentages and frequencies. The chi-square test was used to compare the qualitative variables. The K-S test was used to check the normality of the data. Quantitative variables were compared between groups using the independent sample t-test and the nonparametric Mann-Whitney test. Fisher's exact test was used to compare categorical variables.

RESULTS

A total of 155 patients were included in this study. The mean age of the participants overall was found to be 49. About 108 (69.7%) of the participants were male. Regarding risk factors for urosepsis, diabetes mellitus was found in 54 (34.8%) of the participants. The incidence of urosepsis following PCNL was found to be 3 (1.9%) of the patients. The most frequently reported indication was found to be unilateral renal stones. The most frequently reported type of stone in the analysis was found to be calcium oxalate in nearly two-thirds 98 (63.2%) of the patients.

CONCLUSION

The incidence of urosepsis among the patients who underwent PCNL was less than 2%. Diabetes mellitus, followed by hypertension, were the most prevalent co-morbidities among the participants. Cefuroxime was the antibiotic of choice when treating patients and following urosepsis.

Community-onset urosepsis: incidence and risk factors for 30-day mortality - a retrospective cohort study

BACKGROUND

Urosepsis is a life-threatening condition that needs to be addressed without delay. Two critical issues in its management are: (1) Appropriate empirical antibiotic therapy, considering the patients general condition, comorbidity, and the pathogen expected; and (2) Timing of imaging to identify obstruction requiring decompression.

OBJECTIVES

To identify risk factors associated with 30-day mortality in patients with urosepsis.

METHODS

From a cohort of 1,605 community-onset bloodstream infections (CO-BSI), 282 patients with urosepsis were identified in a Swedish county 2019-2020. Risk factors for mortality with crude and adjusted odds ratios were analysed using logistic regression.

RESULTS

Urosepsis was found in 18% (n = 282) of all CO-BSIs. The 30-day all-cause mortality was 14% (n = 38). After multivariable analysis, radiologically detected urinary tract disorder was the predominant risk factor for mortality (OR = 4.63, 95% CI = 1.47-14.56), followed by microbiologically inappropriate empirical antibiotic therapy (OR = 4.19, 95% CI = 1.41-12.48). Time to radiological diagnosis and decompression of obstruction for source control were also important prognostic factors for survival. Interestingly, 15% of blood cultures showed gram-positive species associated with a high 30-day mortality rate of 33%.

CONCLUSION

The 30-day all-cause mortality from urosepsis was 14%. The two main risk factors for mortality were hydronephrosis caused by obstructive stone in the ureter and inappropriate empirical antibiotic therapy. Therefore, early detection of any urinary tract disorder by imaging followed by source control as required, and antibiotic coverage of both gram-negative pathogens and gram-positive species such as E. faecalis to optimise management, is likely to improve survival in patients with urosepsis.

Comparison of antimicrobial resistance in patients with obstructive pyelonephritis associated with ureteral stones and uncomplicated pyelonephritis

This study aimed to investigate the clinical outcomes of causative microorganisms in obstructive pyelonephritis associated with ureteral stones (OPU) and their antibiotic susceptibilities. This retrospective cohort study included female patients diagnosed with community-acquired acute pyelonephritis (APN) at a tertiary-care hospital between 2008 and 2017. A comparison of APN cases associated with the obstruction of the upper urinary tract by ureteral stones and APN cases without complications was performed. Propensity score (PS) matching was used to adjust the heterogeneity within each group. Of the 588 female patients with community-acquired APN, 107 were diagnosed with OPU and 481 with uncomplicated APN. After PS matching, Enterobacteriaceae strains isolated from OPU cases were more resistant to fluoroquinolones (51.9% vs 16.0%, P < .001). Extended-spectrum β-lactamase was detected in 22.2% and 21.0% of the Enterobacteriaceae strains isolated from OPU and uncomplicated APN cases, respectively (P = 1.000). The treatment failure rate was similar in OPU and uncomplicated APN groups (16.0% vs 21.0%, P = .545). Patients with OPU may be empirically treated with antibiotics in accordance with the treatment protocol for general pyelonephritis. Clinicians should exercise caution in prescribing fluoroquinolones for treating OPU.

Rapid Fluorescence Sensor Guided Detection of Urinary Tract Bacterial Infections

Introduction

Urinary tract infections (UTI) are one of the most serious human bacterial infections affecting millions of people every year. Therefore, simple and reliable identification of the urinary tract pathogenic bacteria within a few minutes would be of great significance for diagnosis and treatment of clinical patients with UTIs. In this study, the fluorescence sensor was reported to guide the detection of urinary tract bacterial infections rapidly.

Methods

The Ami-AuNPs-DNAs sensor was fabricated by the amino-modified Au nanoparticles (Ami-AuNPs) and six DNAs signal molecules, which bound to the urinary tract pathogenic bacteria and generated corresponding response signals. Further, based on the collected response signals, identification was performed by principal component analysis (PCA) and linear discriminant analysis (LDA). The Ami-AuNPs and Ami-AuNPs-DNAs were characterized by transmission electron microscopy, UV−vis absorption spectrum, Fourier transform infrared spectrum, dynamic light scattering and zeta potentials. Thereafter, the Ami-AuNPs-DNAs sensor was used to discriminate and identify five kinds of urinary tract pathogenic bacteria. Moreover, the quantitative analysis performance towards individual bacteria at different concentrations were also evaluated.

Results

The Ami-AuNPs-DNAs sensor were synthesized successfully in terms of spherical, well-dispersed and uniform in size, which could well discriminate five main urinary tract pathogenic bacteria with unique fingerprint-like patterns and was sufficiently sensitive to determine individual bacteria with a detection limit to 1×10⁷ cfu/mL. Furthermore, the sensor had also been successfully applied to identify bacteria in urine samples collected from clinical UTIs.

Conclusion

The developed fluorescence sensor could be applied to rapid and accurate discrimination of urinary tract pathogenic bacteria and holds great promise for the diagnosis of the disease caused by bacterial infection.

Gardnerella vaginalis in Recurrent Urinary Tract Infection Is Associated with Dysbiosis of the Bladder Microbiome

Recent studies on the urine microbiome have highlighted the importance of the gut–vagina–bladder axis in recurrent urinary tract infection (rUTI). In particular, the role of Gardnerella as a covert pathogen that activates E. coli in animal experiments has been reported. Herein, we conducted a human bladder microbiome study to investigate the effect of Gardnerella on rUTI. Urine 16S ribosomal RNA gene sequencing via transurethral catheterization was conducted in the normal control group (NC) (n = 18) and rUTI group (n = 78). The positive detection rate of Gardnerella species did not differ between the NC and rUTI groups (22.2% vs. 18.0%, p = 0.677). In addition, the Gardnerella-positive NC and Gardnerella-positive rUTI groups showed similar levels of microbiome diversity. The Gardnerella-positive group was categorized into three subgroups: the Escherichia-dominant group, Gardnerella-dominant group, and Lactobacillus-dominant group. All of the Escherichia-dominant groups were associated with rUTI. The Gardnerella-dominant or Lactobacillus-dominant groups expressed rUTI with symptoms when risk factors such as the degree of Gardnerella proliferation or causative agents of bacterial vaginosis were present. The presence of Gardnerella in the urine is considered to be related to rUTI depending on other risk factors. New guideline recommendations regarding antibiotic selection based on a novel method to detect the cause of rUTI may be required to reduce antibiotic resistance.

Synergistic Antibacterial Potential of 6-Pentyl-α-pyrone Lactone and Zinc Oxide Nanoparticles against Multidrug-Resistant Enterobacterales Isolated from Urinary Tract Infections in Humans

Urinary tract infection (UTI) is one of the most common bacterial infections in the world, which is associated with high morbidity and mortality rates. Enterobacterales species are considered the most causative agent for UTI, especially uropathogenic Escherichia coli (UPEC). Here, we investigated the antibacterial activity of the green fungal metabolite, 6-pentyl α pyrone lactone, alone or in combination with zinc oxide nanoparticles (ZnONPs) against multidrug-resistant Enterobacterales recovered from UTI. The results revealed that 57.27% of human urine samples were positive for Enterobacterales, where E. coli was the most prevalent bacterial pathogen (66.67%). Of note, 98.41% of Enterobacterales isolates were multidrug-resistant (MDR) with multiple antimicrobial resistance (MAR) indices ranged from 0.437 to 1. Fifty percent of the examined isolates were positive for the integrase gene; 60% out of them harbored class 2 integron, whereas the other 40% carried class 1 integrons. The broth microdilution assay ensured that the 6-pentyl-α-pyrone lactone had a reasonable antimicrobial effect against the examined isolates (Minimum inhibitory concentration (MIC) values of 16–32 μg/mL). However, ZnONPs showed a strong antimicrobial effect against the investigated isolates with MIC values ranging from 0.015 to 32 μg/mL. Interestingly, the MICs decreased 5–12 fold and 3–11 fold for 6-pentyl-α-pyrone lactone and ZnONPs, respectively, against examined isolates after their combination. This is the first report suggesting the use of 6-pentyl α pyrone lactone and ZnONPs combination as a promising candidate against MDR Enterobacterales recovered from UTI.

Transcriptomic and Metabolomic Profiling Reveals That KguR Broadly Impacts the Physiology of Uropathogenic Escherichia coli Under in vivo Relevant Conditions

Urinary tract infections are primarily caused by uropathogenic Escherichia coli (UPEC). In contrast to the intestinal E. coli strains that reside in nutrient-rich gut environment, UPEC encounter distinct niches, for instance human urine, which is an oxygen- and nutrient-limited environment. Alpha-ketoglutarate (KG) is an abundant metabolite in renal proximal tubule cells; and previously we showed that two-component signaling system (TCS) KguS/KguR contributes to UPEC colonization of murine urinary tract by promoting the utilization of KG as a carbon source under anaerobic conditions. However, knowledge about the KguR regulon and its impact on UPEC fitness is lacking. In this work, we analyzed transcriptomic and metabolomic changes caused by kguR deletion under anaerobiosis when KG is present. Our results indicated that 620 genes were differentially expressed in the ΔkguR mutant, as compared to the wild type; of these genes, 513 genes were downregulated and 107 genes were upregulated. Genes with substantial changes in expression involve KG utilization, acid resistance, iron uptake, amino acid metabolism, capsule biosynthesis, sulfur metabolism, among others. In line with the transcriptomics data, several amino acids (glutamate, lysine, etc.) and uridine 5′-diphosphogalactose (involved in capsule biosynthesis) were significantly less abundant in the ΔkguR mutant. We then confirmed that the ΔkguR mutant, indeed, was more sensitive to acid stress than the wild type, presumably due to downregulation of genes belonging to the glutamate-dependent acid resistance system. Furthermore, using gene expression and electrophoretic mobility shift assays (EMSAs), we demonstrate that KguR autoregulates its own expression by binding to the kguSR promoter region. Lastly, we performed a genome-wide search of KguR binding sites, and this search yielded an output of at least 22 potential binding sites. Taken together, our data establish that in the presence of KG, KguR broadly impacts the physiology of UPEC under anaerobiosis. These findings greatly further our understanding of KguS/KguR system as well as UPEC pathobiology.

Assessment of Caspofungin use at a Tertiary Teaching Hospital and compliance with IDSA guidelines and FDA labeling

Objective

The aim of this study is to evaluate the utilization pattern of Caspofungin in an academic tertiary care hospital in Riyadh, Saudi Arabia.

Methods

This is a retrospective study, conducted at King Saud University Medical City, Riyadh, Saudi Arabia. Adult patients who received Caspofungin from January 2015 to December 2018 were included. The appropriate use of Caspofungin was evaluated according to the international guidelines and approved recommendations. Caspofungin doses were assessed according to the FDA-approved loading and maintenance doses as well as dose-adjustment per hepatic function for cirrhotic patients and drug-drug interactions. Cultures and laboratory tests were used to evaluate the appropriate duration of Caspofungin therapy.

Results

388 patients were included. Caspofungin was inappropriately used in 253 (64%) patients. This included 78 (20%) due to inappropriate indication, 165 (42%) due to wrong dosage, and 10 (2%) patients who had a wrong duration of therapy.

Conclusion

The rate of inappropriate use of Caspofungin was high. Hence, developing antifungal stewardship and drug restriction program is highly recommended.

Limited phylogenetic overlap between fluoroquinolone-resistant Escherichia coli isolated on dairy farms and those causing bacteriuria in humans living in the same geographical region

BACKGROUND

Our primary aim was to test whether cattle-associated fluoroquinolone-resistant (FQ-R) Escherichia coli found on dairy farms are closely phylogenetically related to those causing bacteriuria in humans living in the same 50 × 50 km geographical region suggestive of farm-human sharing. Another aim was to identify risk factors for the presence of FQ-R E. coli on dairy farms.

METHODS

FQ-R E. coli were isolated during 2017-18 from 42 dairy farms and from community urine samples. Forty-two cattle and 489 human urinary isolates were subjected to WGS, allowing phylogenetic comparisons. Risk factors were identified using a Bayesian regularization approach.

RESULTS

Of 489 FQ-R human isolates, 255 were also third-generation-cephalosporin-resistant, with strong genetic linkage between aac(6')Ib-cr and blaCTX-M-15. We identified possible farm-human sharing for pairs of ST744 and ST162 isolates, but minimal core genome SNP distances were larger between farm-human pairs of ST744 and ST162 isolates (71 and 63 SNPs, respectively) than between pairs of isolates from different farms (7 and 3 SNPs, respectively). Total farm fluoroquinolone use showed a positive association with the odds of isolating FQ-R E. coli, while total dry cow therapy use showed a negative association.

CONCLUSIONS

This work suggests that FQ-R E. coli found on dairy farms have a limited impact on community bacteriuria within the local human population. Reducing fluoroquinolone use may reduce the on-farm prevalence of FQ-R E. coli and this reduction may be greater when dry cow therapy is targeted to the ecology of resistant E. coli on the farm.

Antibacterial data synthesis challenges: a systematic review of treatments for complicated gram-negative urinary tract infections

Aim: To determine the suitability of network meta-analysis (NMA) using antibacterial treatment evidence in complicated urinary tract infection. Materials & methods: We conducted a systematic literature review to identify published clinical trial data for complicated urinary tract infection treatments. We performed a feasibility assessment to determine whether the available evidence would support the creation of a robust NMA, considering key assumptions of homogeneity, similarity and consistency. Results: Twenty-five trials met eligibility criteria. Risk of bias was low, and individual studies met their primary end point(s). Assumptions central to the conduct of a robust NMA were not met. Heterogeneity was ubiquitous, including baseline pathogen, treatment and patient characteristics. Conclusion: Limited and heterogeneous data identified make the use of NMA to compare novel antibacterial agents impractical and likely unreliable.

Molecular mechanisms in septic shock (Review)

Sepsis is a clinical syndrome defined by the presence of infection and systemic inflammatory response to infection and results from a complex interaction between the host and infectious agents. It is characterized by the activation of multiple inflammatory pathways, with an increased risk of mortality. The incidence of sepsis has been on an ever-increasing pathway in recent years. Sepsis can be induced by several clinical situations that predispose to its occurrence: malignant tumors, organ transplantation, AIDS, radiation therapy, burns, sores, polytrauma, diabetes mellitus, hepatic failure, renal failure, malnutrition, catheters or different invasive devices, and urinary catheters. The microorganisms involved in the pathogenesis of sepsis are Gram-positive cocci (Staphylococci, Streptococci) and Gram-negative bacilli (Klebsiella, Pseudomonas aeruginosa, E. coli), fungi (Candida), parasites, and viruses. Among mechanisms involved in septic shock production, two pathological phenomena appear: the profound decompensation of circulation and metabolic disturbances that evolve towards an irreversible state. The intimate mechanism of shock involves the activation of monocytes, macrophages and neutrophils by lipopolysaccharides of Gram-negative bacteria. The microvascular bed is directly involved in the etiopathogenesis of disorders of acute inflammatory states associated with or without sepsis. A better comprehension of sepsis pathophysiology, especially the molecular mechanisms of septic shock, allows for new therapeutic perspectives.

Bis-molybdopterin guanine dinucleotide modulates hemolysin expression under anaerobiosis and contributes to fitness in vivo in uropathogenic Escherichia coli

Uropathogenic Escherichia coli (UPEC) is the primary causative agent of urinary tract infections (UTIs). Successful urinary tract colonization requires appropriate expression of virulence factors in response to host environmental cues, such as limited oxygen and iron availability. Hemolysin is a pore-forming toxin, and its expression correlates with the severity of UPEC infection. Previously, we showed that hemolysin expression is enhanced under anaerobic conditions; however, the genetic basis and regulatory mechanisms involved remain undefined. Here, a transposon-based forward screen identified bis-molybdopterin guanine dinucleotide cofactor (bis-MGD) biosynthesis as an important factor for a full transcription of hemolysin under anaerobiosis but not under aerobiosis. bis-MGD positively influences hemolysin transcription via c3566-c3568, an operon immediately upstream of and cotranscribed with hlyCABD. Furthermore, suppressor mutation analysis identified the nitrogen regulator NtrC as a direct repressor of c3566-c3568-hlyCABD expression, and intact bis-MGD biosynthesis downregulated ntrC expression, thus at least partially explaining the positive role of bis-MGD in modulating hemolysin expression. Finally, bis-MGD is involved in hemolysin-mediated uroepithelial cell death and contributes to the competitive fitness of UPEC in a murine model of UTI. Collectively, our data establish that bis-MGD biosynthesis plays a crucial role in UPEC fitness in vivo, thus providing a potential target for combatting UTIs.

The Urosepsis-A Literature Review

Urosepsis is a very serious condition with a high mortality rate. The immune response is in the center of pathophysiology. The therapeutic management of these patients includes surgical treatment of the source of infection, antibiotic therapy and life support. The management of this pathology is multidisciplinary and requires good collaboration between the urology, intensive care, imaging and laboratory medicine departments. An imbalance of pro and anti-inflammatory cytokines produced during sepsis plays an important role in pathogenesis. The study of cytokines in sepsis has important implications for understanding pathophysiology and for development of other therapeutic solutions. If not treated adequately, urosepsis may lead to serious septic complications and organ sequelae, even to a lethal outcome.

Risk factors for urosepsis in chronic kidney disease patients with urinary tract infections

Occurrence of urosepsis is not uncommon following urinary tract infections (UTI). However, there is a lack of evidence explaining the risk factors predisposing to urosepsis in patients with chronic kidney disease (CKD). This retrospective study was undertaken to evaluate the incidence and possible risk factors for urosepsis among patients hospitalized with UTI in a cohort of CKD patients. Patients were divided into the urosepsis group and the non-urosepsis group. Of 489 hospitalized patients with UTI, 70 (14.3%) acquired urosepsis. Stepwise multivariate logistic regression demonstrated that diabetes, urinary catheter and length of hospital stay (p < 0.001 for all) were significant independent predictive risk factors for urosepsis in CKD patients with UTI in addition to age, glomerular filtration rate, hydronephrosis, acute kidney injury and E. coli infection (p < 0.05 for all). Finally, Klebsiella spp. cases were associated with significantly higher odds for urosepsis than E. coli cases (OR: 3.5, 95% CI: 2.86-7.23, p < 0.001 vs. OR: 1.38, 95% CI: 1.19-3.69, p = 0.038). Diabetes, presence of an indwelling urinary catheter, length of hospitalization, and infection with Klebsiella spp were independent risk factors for urosepsis in CKD patients with UTI.

Urological Emergencies and Diseases in Wilderness Expeditions

When considering medical emergencies that might affect an expedition, urologic emergencies are typically not included. However, the reality is that manageable and prevalent urologic disease processes can pose significant challenges for the wilderness medicine physician and warrant consideration. The purpose of this review is to identify and discuss the most commonly encountered urologic emergencies and diseases in the wilderness setting and to prepare the expedition medicine physician for management of these urgent conditions. A PubMed and Internet search for urologic emergencies and diseases in wilderness conditions was conducted. We also searched bibliographies for useful supplemental literature and material from leading mountain medicine and wilderness medicine societies as well as population-based studies for common urologic diseases. Urologic emergencies and diseases on expeditions and in wilderness conditions have been reported primarily with retrospective case series and case reports. The most commonly reported urologic emergencies in this setting include urologic trauma, renal calculi, and urinary retention. Parasitic infections in the urinary tract also have been reported to cause urinary symptoms and urinary retention in wilderness conditions. Although urologic diseases in such conditions are uncommon, significant morbidity and even potentially life-threatening sequelae to urologic emergencies were found to occur. Major genitourinary emergencies in expedition medicine are uncommon but involve both potentially manageable urgent conditions and serious life-threatening conditions best treated with urgent stabilization and occasionally medical evacuation. The opportunity exists for increased awareness for management strategies for urologic conditions in the often remote or extreme environments of an expedition.

Proteomic Signature of Urosepsis: From Discovery in a Rabbit Model to Validation in Humans

Urosepsis after upper urinary tract endoscopic lithotripsy (UUTEL) may cause uroseptic shock with high mortality, which can be prevented if early diagnosis and timely intervention are implemented with help of a diagnostic protein panel. The plasma of five rabbits of uroseptic shock and five controls was subjected to exploratory proteomics to search biomarker candidates from proteomic profiles related to uroseptic shock. Then, plasma from 21 nonsepsis and 20 urosepsis patients according to European diagnostic criteria of sepsis was enrolled in the validation study via targeted proteomics. Changes in a massive number of plasma proteins, mainly enriched in immune regulation, coagulation, structural repair, and transport activity, were observed in the rabbit model of septic shock. Fifteen proteins were identified as differential expression proteins between sepsis and nonsepsis patients. A diagnostic model composed of three proteins lipopolysaccharide-binding protein (LBP), clusterin (CLU), and vascular cell adhesion protein 1 (VCAM1) was developed for the early detection (2 hours postoperatively) of urosepsis after UUTEL, with a high area under the receiver operating characteristic (ROC) curve of 0.921. In conclusion, changes in the proteomic profile may reflect the underlying biological mechanisms during the development of urosepsis and produce diagnostic biomarkers for the early detection of urosepsis after UUTEL.

Outcomes for Patients with Urinary Tract Infection After an Initial Intravenous Antibiotics Dose Before Emergency Department Discharge

INTRODUCTION

To investigate the effect of single-dose intravenous antibiotics before emergency department (ED) discharge on the outcomes of patients with urinary tract infections (UTIs).

METHODS

This is a retrospective study conducted at the EDs of three medical centers. Patients aged over 18 years who presented to the ED with UTI and were discharged without admission between January 1, 2016 and December 31, 2017 were evaluated. The study group received a single dose of effective intravenous antibiotics on the basis of urine culture during the index ED visit following oral antibiotics, while the comparison group received oral antibiotics only. The primary outcomes were ED revisit within 72 h and admission following the return visit.

RESULTS

A total of 8168 patients were included. Of these, 20.9% received intravenous antibiotics before ED discharge. Patients who received effective intravenous antibiotics before ED discharge were associated with less than 72-h ED revisit (adjusted odds ratio [OR] 0.791, 95% confidence interval [CI] 0.640-0.979]), but not decreased admission following the return visit (adjusted OR 0.921, 95% CI [0.731-1.153]). In subgroup analysis, parenteral antibiotic use during the index ED visit was associated with decreased admission following ED revisit in patients who presented with fever (adjusted OR 0.605; 95% CI 0.443-0.932).

CONCLUSION

For patients with UTI and clinically well to be discharged from the ED, a single dose of effective intravenous antibiotics before ED discharge was associated with decreased 72-h ED revisit. In patients with febrile UTI, initial intravenous antibiotics were associated with decreased revisit leading to admissions.

Development of a fluorescent distance-based paper device using loop-mediated isothermal amplification to detect Escherichia coli in urine

The highly sensitive and selective determination of Escherichia coli (E. coli) in urine was achieved using a SYBR™ safe loop-mediated isothermal amplification (LAMP) method with a distance-based paper device. New primers set specific to multi-copy the 16s rRNA gene of E. coli were designed and used in this study. The detection sensitivity of these primers was higher than in related work and they could be incorporated with a low-cost paper-based device to quantify E. coli in urine at a concentration lower than 101 CFU mL-1. Regarding standard artificial urine, a linear range of a 10-fold dilution of E. coli concentration (105-100 CFU mL-1) with an R-square value (R2) = 0.9823 was observed directly using a fluorescent migratory distance of the 4 μL reaction mixture in the detection zone under blue light without the need for postreaction staining process. Based on the device, E. coli infection could be significantly categorized into 3 groups; none, light, and heavy levels, which is beneficial for UTI diagnosis. Hence, this paper-based device is suitable for use with the SYBR™ Safe-LAMP assay to semi-quantify E. coli, especially in resource-limited settings due to advantages of low cost, simple fabrication and operation, and no requirement for sophisticated instruments, as well as its disposability and portability.

Reducing contamination of midstream urine samples through standardized collection processes: a best practice implementation project

OBJECTIVE

The objective of this project is to decrease the rates of midstream urine sample contamination through standardization of evidence-based techniques among nurses.

INTRODUCTION

Urinary tract infection is a prevalent health problem worldwide. The diagnosis and treatment of urinary tract infection depend on a thorough physical examination and the results of an uncontaminated midstream specimen of urine. However, improper techniques used in the collection often cause sample contamination, leading to delayed diagnosis and the use of inappropriate antibiotics for treatment. As nurses are at the forefront of care delivery, they are involved in reducing the rates of midstream urine sample contamination. Thus, the use of an evidence-based approach to standardize collection of midstream urine culture is crucial for the provision of higher-quality patient care.

METHODS

Education sessions were delivered to the nurses and an evidence-informed standardized patient education leaflet was crafted by the project team for implementation. With a sample size of 30 nurses and patients, the project took place in a 21-bed adult surgical ward in a hospital in Singapore. The JBI Practical Application of Clinical Evidence System (JBI PACES) and Getting Research into Practice (GRiP) programs were used to implement the evidence-based project. The project was implemented in three phases from October 2018 to January 2019. A standardized audit tool devised from JBI PACES was used for the audits in this project. The rates of midstream urine specimen contamination and the knowledge of nurses were also monitored.

RESULTS

The baseline audit revealed that the nursing staff required educational sessions to improve their knowledge of midstream urine sample collection. Aside from criteria 1,3 and 4, the remaining criteria achieved compliance of more than 80%. The criteria below 80% compliance became the main focus of the project interventions. At follow-up cycle 1, all criteria achieved at least 80% compliance except criteria 4 and 5, which achieved 73% and 69% compliance, respectively. At the three-month post implementation audit, all criteria achieved a compliance rate of at least 80%. Fisher's exact test was carried out, and statistical significance of the results was achieved (p < 0.001) when compared to baseline audit. The rates of midstream urine specimen contamination also significantly decreased from 40% at the baseline audit to 20% at the third-month post implementation audit. Nurses' knowledge markedly improved as measured by the three-question quiz.

CONCLUSION

This evidence-based implementation project highlights the effectiveness of the JBI PACES and GRiP processes for initiating best practice within a nursing environment. The use of JBI best-practice recommendations to standardize methods for midstream urine specimen collection effectively reduced the rates of midstream urine contamination.

Analysis of Selection Methods to Develop Novel Phage Therapy Cocktails Against Antimicrobial Resistant Clinical Isolates of Bacteria

Antimicrobial resistance (AMR) is a major problem globally. The main bacterial organisms associated with urinary tract infection (UTI) associated sepsis are E. coli and Klebsiella along with Enterobacter species. These all have AMR strains known as ESBL (Extended Spectrum Beta-Lactamase), which are featured on the WHO priority pathogens list as "critical" for research. Bacteriophages (phages), as viruses that can infect and kill bacteria, could provide an effective tool to tackle these AMR strains. There is currently no "gold standard" for developing a phage cocktail. Here we describe a novel approach to develop an effective phage cocktail against a set of ESBL-producing E. coli and Klebsiella largely isolated from patients in United Kingdom hospitals. By comparing different measures of phage efficacy, we show which are the most robust, and suggest an efficient screening cascade that could be used to develop phage cocktails to target other AMR bacterial species. A target panel of 38 ESBL-producing clinical strains isolated from urine samples was collated and used to test phage efficacy. After an initial screening of 68 phages, six were identified and tested against these 38 strains to determine their clinical coverage and killing efficiency. To achieve this, we assessed four different methods to assess phage virulence across these bacterial isolates. These were the Direct Spot Test (DST), the Efficiency of Plating (EOP) assay, the planktonic killing assay (PKA) and the biofilm assay. The final ESBL cocktail of six phages could effectively kill 23/38 strains (61%), for Klebsiella 13/19 (68%) and for E. coli 10/19 (53%) based on the PKA data. The ESBL E. coli collection had six isolates from the prevalent UTI-associated ST131 sequence type, five of which were targeted effectively by the final cocktail. Of the four methods used to assess phage virulence, the data suggests that PKAs are as effective as the much more time-consuming EOPs and data for the two assays correlates well. This suggests that planktonic killing is a good proxy to determine which phages should be used in a cocktail. This assay when combined with the virulence index also allows "phage synergy" to inform cocktail design.

The management of urinary tract infections in older patients within an urgent care out-of-hours setting

This article critically analyses the prevalence, assessment and management of urinary tract infections (UTIs) in patients over the age of 65, in an urgent care out-of-hours service in order to enhance care. It is undertaken from the perspective of working as an Advanced Nurse Practitioner (ANP). A synopsis of UTI is presented, examining the epidemiology and aetiology. The process of assessment, diagnosis and management of UTI in older people is appraised based on current evidence. Difficulties associated with the recognition of UTI in elderly are evaluated. Finally, recommendations are made for the improvement of future practice as an ANP.

Patients' poor performance status is an independent risk factor for urosepsis induced by kidney and ureteral stones

This study was aimed to identify the risk factors for urosepsis caused by kidney and ureteral stones. One hundred and nine patients who had kidney or ureteral stones and who were treated with trans-ureteral lithotripsy (TUL) at our institution from 2016 to 2020 were included. We investigated the risk factors for urosepsis caused by kidney or ureteral stones that occurred prior to TUL. Thirty patients (28%) had urosepsis prior to TUL. Patients were divided into a urosepsis group (n = 30, 28%) and a non-urosepsis group (n = 79, 72%). Patients' characteristics (gender, age, performance status [PS] score, presence of diabetes mellitus, and skeletal muscle mass), as well as their stone and urine characteristics (stone size, presence of obstructive ureteral stones, stone composition, and urine and stone cultures), were compared between the two groups. When compared to the non-urosepsis group, patients with urosepsis were more likely to be older (p < 0.001), female (p < 0.001), with lower skeletal muscle mass (p < 0.001) and with poor PSs (p < 0.001). For stone and urine characteristics, infection stones (p = 0.01), positive urine (p < 0.001) and stone culture (p = 0.007) were more often detected in patients with urosepsis. A multivariate analysis showed patients' poor PS to be an independent risk factor for urosepsis due to kidney and ureteral stones (OR = 15.7; 95% CI = 2.2-115, p = 0.007). Our study revealed that the most significant risk factor for urosepsis caused by kidney and ureteral stones was the patients' poor PS.

Urinary Tract Infection after Elective Spine Surgery: Timing, Predictive Factors, and Outcomes

STUDY DESIGN

Retrospective review of prospectively collected data.

OBJECTIVE

The aim of this study was to investigate risk factors associated with the timing of urinary tract infection (UTI) after elective spine surgery, and to determine whether postoperative UTI timing affects short-term outcomes.

SUMMARY OF BACKGROUND DATA

Urinary tract infection (UTI) is a common post-surgical complication; however, the predominant timing, location, and potential differential effects have not been carefully studied.

METHODS

We analyzed elective spine surgery patients from 2012 to 2018 in the ACS National Surgical Quality Improvement Program (NSQIP). We grouped patients with postoperative UTI by day of onset relative to discharge, to create cohorts of patients who developed inpatient UTI and post-discharge UTI. We compared both UTI cohorts with a control (no UTI) population and with each other to identify differences in baseline characteristics including demographic, comorbidity and operative factors. We performed multivariate logistic regression to identify predictors of UTI in each cohort and to assess adjusted risks of poor outcomes associated with UTI timing.

RESULTS

A total of 289,121 patients met inclusion criteria and 0.88% developed UTI (n = 2553). Only 31.6% of UTIs occurred before discharge (n = 806), with 68.4% occurring after discharge (n = 1747). The inpatient UTI cohort had significantly longer operative time, more fusion procedures, more posterior procedures, and more procedures involving the lumbar levels than the post-discharge cohort. Predictors of inpatient UTI included procedure type, spine region, and approach. Predictors of post-discharge UTI included length-of-stay and discharge destination. Both UTI cohorts were significantly associated with sepsis; however, post-discharge UTI carried a higher odds (adjusted odds ratio [aOR] = 24.90, 95% confidence interval [CI] = 21.05-29.45, P < 0.001 vs. aOR = 14.31, 95% CI = 11.09-18.45, P < 0.001). Inpatient UTI was not associated with 30-day readmission, although post-discharge UTI was (aOR = 8.23, 95% CI = 7.36-9.20, P < 0.001). Conversely, inpatient UTI was associated with increased odds of 30-day mortality (aOR = 3.23, 95% CI = 1.62-6.41, P = 0.001), but post-discharge UTI was not.

CONCLUSION

Predictive factors and outcomes differ based on timing of UTI after elective spine surgery. Before discharge, procedure -specific details predict UTI, but after discharge they do not. These findings suggest that traditional thinking about UTI prevention may need modification.Level of Evidence: 3.

A Case Report on Distinguishing Emphysematous Pyelitis and Pyelonephritis on Point-of-care Ultrasound

Introduction

Point-of-care ultrasound (POCUS) in the emergency department (ED) is being performed with increasing frequency. The objective of this study was to demonstrate how utilization of POCUS can help the emergency physician recognize emphysematous pyelitis (EP) and emphysematous pyelonephritis (EPN).

Case Report

A 60-year-old female presented to the ED with normal vital signs and intermittent left-sided flank pain that radiated to her groin. She also had a history of obstructive nephrolithiasis. Within 20 minutes of arrival she became febrile (101.2°Fahrenheit), tachycardic (114 beats per minute), tachypneic (21 breaths per minute), and had a blood pressure of 114/82 millimeters mercury. POCUS was conducted revealing heterogeneous artifact with “dirty shadowing” within the renal pelvis, which was strongly suggestive of air. The emergency physician ordered a computed tomography (CT) to confirm the suspicion for EP and started the patient on broad-spectrum antibiotics. The CT showed a 1.3-centimeter calculus and hydronephrosis with foci of air. The patient received intravenous antibiotics and had an emergent nephrostomy tube placed. Urine cultures tested positive for pan-sensitive Escherichia Coli. Urology was consulted and a repeat CT was obtained to show correct drainage and decreased renal pelvis dilation.

Conclusion

Distinctly different forms of treatment are used for EP and EPN, despite both having similar pathophysiology. In EP, air can be seen in the renal pelvis on POCUS, as in this case study, which distinguishes it from EPN. In the case of our patient, the use of POCUS was useful to aid in rapid differentiation between EP and EPN.

Urosepsis in Older Adults: Epidemiologic Trends in Florida

The incidence and geographic distribution of urosepsis, a life-threatening condition in older adults, is not well understood. The Florida State Inpatient Databases (2012-2014) showed an increase in the incidence of community-acquired urosepsis (5.37 to 6.16 per 1000), particularly among Hispanic older adults residing in low socioeconomic, urban areas with large numbers of nursing homes. These findings suggest a state policy is needed to address community-based preventative care and education for early detection of urosepsis in low-income urban areas. It is important for local health departments to partner with nursing homes to address disparities in care that disproportionally impact Hispanics.

Risk factors for uroseptic shock in hospitalized patients aged over 80 years with urinary tract infection

Background

The purpose of this study was to compare clinical characteristics and outcomes in individuals of different age groups with urinary tract infection (UTI), and to identify the relationships among advanced age and uroseptic shock.

Methods

This retrospective study compared clinical characteristics and outcomes in patients in different age groups with UTI and identified relationships between advanced age and uroseptic shock among hospitalized patients with UTI in an acute hospital care setting from January 2006 to October 2018. Patients were divided into young (age below 65 years), old (65–80 years), and very old (above 80 years) groups.

Results

Of 1,043 participants, 269 (25.8%) were very old and 200 (19.2%) developed uroseptic shock. Very old age [odds ratio (OR) 1.99, 95% confidence interval (CI): 1.25–3.19, P=0.004], male (OR 1.54, 95% CI: 1.07–2.24, P=0.022), presented flank pain (OR 1.54, 95% CI: 1.05–2.24, P=0.025), congestive heart failure (CHF) (OR 2.54, 95% CI: 1.27–5.06, P=0.008), acute kidney injury (AKI) (OR 4.19, 95% CI: 2.78–6.30, P<0.001), bacteremia (OR 1.78, 95% CI: 1.25–2.53, P=0.001), and multiple drug-resistant (MDR) bacteria (OR 1.43, 95% CI: 1.02–2.00, P=0.039) were associated with an increased risk of uroseptic shock in patients with UTI. In very old patients with UTI, bacteremia (OR 2.54, 95% CI: 1.38–4.69, P=0.003) and AKI (OR 4.37, 95% CI: 2.15–8.90, P<0.001) were independently associated with uroseptic shock.

Conclusions

Very old patients with UTI had a higher risk of developing uroseptic shock than younger patients. Bacteremia was an independent risk factor for uroseptic shock in very old patients with UTI.

Urolithiasis Is a Risk Factor for Uroseptic Shock and Acute Kidney Injury in Patients With Urinary Tract Infection

Urinary tract infection (UTI) is a common complication in patients with urolithiasis. This study aimed to compare clinical manifestations and treatment outcomes among UTI patients with or without urolithiasis. It also focused on identifying relationships among urolithiasis, uroseptic shock, and acute kidney injury (AKI). This retrospective study enrolled hospitalized UTI patients who underwent imaging in an acute care setting from January 2006 to March 2015. Of 662 participants enrolled, 113 (17.1%) had urolithiasis, 107 (16.2%) developed uroseptic shock, and 184 (27.8%) developed AKI. A multivariate logistic regression analysis showed that in UTI patients, urolithiasis is associated with an increased risk of uroseptic shock (OR 1.80, 95% CI: 1.08-3.02, P = 0.025), AKI (OR 1.95, 95% CI: 1.22-3.12, P = 0.005), and bacteremia (OR 1.68, 95% CI: 1.08-2.64, P = 0.022). Urolithiasis is common in UTI patients and is associated with an increased risk of uroseptic shock and AKI.

Human single-chain antibodies that neutralize Pseudomonas aeruginosa-exotoxin A-mediated cellular apoptosis

Targeting bacterial virulence factors directly provides a new paradigm for the intervention and treatment of bacterial diseases. Pseudomonas aeruginosa produces a myriad of virulence factors to cause fatal diseases in humans. In this study, human single-chain antibodies (HuscFvs) that bound to P. aeruginosa exotoxin A (ETA) were generated by phage display technology using recombinant ETA, ETA-subdomains and the synthetic peptide of the ETA-catalytic site as baits for selecting ETA-bound-phages from the human-scFv phage display library. ETA-bound HuscFvs derived from three phage-transfected E. coli clones neutralized the ETA-induced mammalian cell apoptosis. Computerized simulation demonstrated that these HuscFvs used several residues in their complementarity-determining regions (CDRs) to form contact interfaces with the critical residues in ETA-catalytic domain essential for ADP-ribosylation of eukaryotic elongation factor 2, which should consequently rescue ETA-exposed-cells from apoptosis. The HuscFv-treated ETA-exposed cells also showed decremented apoptosis-related genes, i.e., cas3 and p53. The effective HuscFvs have high potential for future evaluation in animal models and clinical trials as a safe, novel remedy for the amelioration of exotoxin A-mediated pathogenesis. HuscFvs may be used either singly or in combination with the HuscFv cognates that target other P. aeruginosa virulence factors as an alternative therapeutic regime for difficult-to-treat infections.

Evaluation of Acridine Orange Staining for a Semi-Automated Urinalysis Microscopic Examination at the Point-of-Care

A urinary tract infection (UTI) can be diagnosed via urinalysis, consisting of a dipstick test and manual microscopic examination. Point-of-care (POC) image-based systems have been designed to automate the microscopic examination for low-volume laboratories or low-resource clinics. In this pilot study, acridine orange (AO) was evaluated as a fluorescence-based contrast agent to aid in detecting and enumerating urine sediment specific for diagnosing a UTI. Acridine orange staining of epithelial cells, leukocytes, and bacteria provided sufficient contrast to successfully implement image segmentation techniques, which enabled the extraction of classifiable morphologic features. Surface area bounded by each cell border was used to differentiate the sediment; epithelial cells were larger than 500μm², bacteria were less than 30μm², and leukocytes in between. This image-based semi-automated technique using AO resulted in similar cell counts to the clinical results, which demonstrates the feasibility of AO as an aid for POC urinalysis systems.

Increased fluid intake for the prevention of urinary tract infection in adults and children in all settings: a systematic review

BACKGROUND

Non-antibiotic interventions for urinary tract infection (UTI) prevention have been investigated as a strategy to reduce antibiotic prescribing for UTI and subsequent antibiotic resistance. Increased hydration is widely advocated for preventing UTI; however, evidence for its effectiveness is unknown.

AIM

To systematically review the published literature on the effectiveness of increased fluid intake as a preventive intervention for UTI in adults and children in any setting.

METHODS

Five electronic databases were searched from inception to February 2019 to identify published randomized controlled trials (RCTs) and quasi-experimental studies evaluating the effectiveness of high (≥1.5 L/24 h) versus normal/low (<1.5 L/24 h) fluid intake for UTI prevention. The outcome was UTI incidence. Risk of bias was assessed using the Cochrane Collaboration's tool. Due to the small number of studies identified, meta-analysis was not possible. Hence a narrative synthesis was undertaken.

FINDINGS

Of the 2822 potentially relevant papers, two were eligible for inclusion: an RCT (individual randomization) and a cluster-RCT. Both studies differed regarding participants, setting, sample size, UTI definition, and intervention. The RCT was assessed as having a low risk of bias whereas the cluster-RCT had a high risk of bias. Only the RCT, which included healthy premenopausal women visiting primary care clinics, demonstrated statistical significance for the effect of high fluid intake for UTI prevention.

CONCLUSION

The lack of enough adequately powered and robust RCTs highlights the need for further research on the effectiveness of this intervention for UTI prevention.

Pain intensity and imaging at the initial phase of acute pyelonephritis

OBJECTIVE

To identify predictive factors of urological complication on imaging findings in women with pyelonephritis aged 18 to 65 years.

METHODS

We performed an observational, retrospective, single-center study. The medical charts of women diagnosed with pyelonephritis at the emergency department from 2010 to 2015 were reviewed. Only patients who underwent an imaging study at the emergency department and with microbiologically confirmed pyelonephritis were included for analysis. The primary endpoint was the presence of urological complications on imaging findings. The secondary endpoint was treatment changes after imaging diagnosis.

RESULTS

Of the 193 women enrolled, 88 (45.6%) had urological complication(s) on imaging findings. The multivariate analysis revealed that history of urolithiasis (OR=2.41; P=0.01) and pain requiring morphine use (OR=5.29; P=0.009) were predictive of urological complications on imaging findings. Of the 120 women with uncomplicated pyelonephritis who underwent imaging studies, 45% had urological complication, resulting in a treatment change in 36.7% of patients. The multivariate analysis revealed that age>40 years (OR=4.58; P=0.02) and pain requiring morphine use (OR=3.78; P=0.02) were predictive of urological complication(s) on imaging findings and of treatment change based on imaging findings (OR=6.76; P=0.005 and OR=4.19; P=0.01 respectively) in this subgroup.

CONCLUSIONS

Pain requiring morphine use, age, and history of urolithiasis are independent predictors of urological complications on imaging findings in patients with acute pyelonephritis.

Urinary sepsis after endourological ureterorenoscopy for the treatment of lithiasis

OBJECTIVE

To evaluate the incidence, clinical presentation and factors associated with the development of urinary sepsis after performing ureterorenoscopy.

MATERIAL AND METHODS

Retrospective study of patients undergoing ureterorenoscopy for the treatment of lithiasis between July 2015 and October 2017. Patients who developed urinary sepsis during the 30 days following the intervention were identified. Personal, clinical, surgical and microbiological backgrounds were collected. Statistical analysis was performed with the Chi squared test (or Fisher's exact test), Student's t (or U Mann-Whitney) or logistic regression as appropriate.

RESULTS

246 ureterorenoscopies were performed, 184 (74.8%) on ureteral stones and 62 (25.2%) on kidney stones, with a mean age of 52 (44.5-59.5) years. After procedure, 18 (7.3%) patients developed urinary sepsis, 10 of them (55.5%) occurred in the first 24h. The urine culture showed enterobacteria (61.1%) and enterococci (38.9%). The antibiogram showed greater sensitivity to nitrofurantoins (100%) and quinolones (72%). The statistical analysis showed that female sex, the clinical debut of urolithiasis as urinary sepsis, having received antibiotic or having required urinary diversion by a double J during debut, positive presurgical uroculture and the persistence of residual lithiasis after surgery were significantly associated (P<.05) with the development of urinary sepsis after ureterorenoscopy.

CONCLUSION

Urinary sepsis is a complication that appears after performing ureterorenoscopy, especially in female patients with a history of urinary sepsis, antibiotic therapy, double J, previous positive urine culture or residual lithiasis after the procedure.

Regulation of NF-κB/MAPK signaling pathway attenuates the acute lung inflammation in Klebsiella pneumonia rats by mollugin treatment

Present study evaluates the protective effect of mollugin against Klebsiella pneumonia (KP) and also postulates the possible mechanism of its action. Klebsiella pneumoniae (2.4 × 10⁸ CFU/ml) was used for the induction of KP. PMNs and WBC count was determined in the blood and bronchoalveolar lavage fluid (BALF) of Klebsiella pneumonia rat. Level of inflammatory cytokines in the blood of Klebsiella pneumonia rat was determined by ELISA methods. Moreover effect of mollugin was estimated by Western blot assay and RT-PCR method. Result of the study suggests that water content in lung was reduced in the mollugin treated group compared to pneumonia control group of rats. Count of PMNs and WBC were found to be reduced in mollugin treated group compared to pneumonia control group of rats. Level of inflammatory cytokines was also found to be reduced in the blood of mollugin treated group than pneumonia control group. Moreover treatment with mollugin attenuates the altered expression of p-MAPK, p-JNK and p-ERK protein and mRNA expression of NF-κB in the lung tissues of Klebsiella pneumonia rat. In conclusion, data of the study reveals that treatment with mollugin ameliorates Klebsiella pneumonia rat by reducing the lung inflammation. Inflammation of lung tissue was reduced by regulating the NF-κB/MAPK signaling pathway in mollugin treated group.

Diagnosis of Urinary Tract Infections by Urine Flow Cytometry: Adjusted Cut-Off Values in Different Clinical Presentations

Background

Bacterium and leucocyte counts in urine can be measured by urine flow cytometry (UFC). They are used to predict significant bacterial growth in urine culture and to diagnose infections of the urinary tract. However, little information is available on appropriate UFC cut-off values for bacterium and leucocyte counts in specific clinical presentations.

Objective

To develop, validate, and evaluate adapted cut-off values that result in a high negative predictive value for significant bacterial growth in urine culture in common clinical presentation subgroups.

Methods

This is a single center, retrospective, observational study with data from patients of the emergency department of Bern University Hospital, Switzerland, with suspected infections of the urinary tract. The patients presented with different symptoms, and urine culture and urine flow cytometry were performed. For different clinical presentations, the patients were grouped by (i) age (>65 years), (ii) sex, (iii) clinical symptoms (e.g., fever or dysuria), and (iv) comorbidities such as diabetes and immunosuppression. For each group, cut-off values were developed, validated, and analyzed using different strategies, i.e., linear discriminant analysis (LDA) and Youden's index, and were compared with known cut-offs and cut-offs optimized for sensitivity.

Results

613 patients were included in the study. Significant bacterial growth in urine culture depended on clinical presentation and ranged from 32.3% in male patients to 61.5% in patients with urinary frequency. In all clinical presentations, the predictive accuracy of UFC leucocyte and UFC bacterium counts was good for significant bacterial growth in urine culture (AUC ≥ 0.88). The adapted LDA₉₅ equations did not exhibit consistently high sensitivity. However, the in-house cut-offs (test positive if UFC leucocytes > 17/μL or UFC bacteria > 125/μL) were highly sensitive (>90%). In female, younger, and dysuric patients, even higher cut-offs for UFC leucocytes (169/μL, 169/μL, and 205/μL) exhibited high sensitivity. Specificity was insufficient (<0.9) for all tested cut-offs.

Conclusions

For various clinical presentations, significant bacterial growth in urine culture can be excluded if flow cytometry measurements give a bacterial count of ≤125/μL or a leucocyte count of ≤17/μL. In female patients, dysuric patients, and patients younger than ≤65 years, the leucocyte cut-off can be increased to 170/μL.

Management and outcome of obstructive ureteral stones in the emergency department: Emphasis on urine tests and antibiotics usage

BACKGROUND

Kidney stone related complaints in the Emergency Department (ED) are common. Current guidelines recommend antibiotic therapy for infected obstructive stones and stone removal in a timely fashion, but there is no clear recommendation for prophylactic antibiotic use for bacteriuria or pyuria in the setting of obstructive ureteral stones.

OBJECTIVES

The aim of this study is to evaluate the current management of patients with obstructive ureteral stones in a single ED with emphasis on urine tests and antibiotics use.

METHODS

The picture archiving and communication system (PACS) was used to filter the list of patients who received a computed tomography (CT) scan of the abdomen and pelvis that positively identified obstructive ureteral stones. Demographics and clinical data were also recorded and analyzed.

RESULTS

Of the patients discharged, 278 patients did not receive antibiotics in the ED or a prescription. Of these, 8 patients had positive culture, 4 patients followed up, and one developed and was treated for a urinary-tract infection. One hundred ninety two patients were not given antibiotics in the ED but received an antibiotics prescription, and 4 patients had positive cultures grow. Two followed up and had no infection-related complications. Fourteen patients were discharged without a prescription after receiving a single dose of antibiotics in the ED, with no positive urine cultures and 9 patients following up without complication.

CONCLUSION

Antibiotics were given at the discretion of the provider without clear pattern. A high rate of infectious complication did not occur in the followed up patient group.

Bacteremia complicating urinary tract infection by Pseudomonas aeruginosa: Mortality risk factors

OBJECTIVES

To examine the clinical risk factors for death within 30 days of diagnosis of Pseudomonas aeruginosa-causing bacteremia after a urinary tract infection.

METHODS

A total of 62 patients with Pseudomonas aeruginosa isolated from both urine and blood at the same episode from January 2009 to December 2016 were enrolled in the present study. We retrospectively investigated clinical risk factors for death by comparison between surviving patients and those who died within 30 days after diagnosis of P. aeruginosa bacteremia. The comparison for risk factors for bacteremia-related death included 31 categories, such as age, laboratory data, underlying diseases, clinical history, history of surgery, care in the intensive care unit, P. aeruginosa susceptibility to the antibiotics used at the time of bacteremia diagnosis and consultation with urological department.

RESULTS

The study included 48 men and 14 women aged 71.3 ± 10.4 years. Nine patients (14.5%) died of P. aeruginosa bacteremia. Statistical analysis showed that non-survivors had significantly lower albumin levels than survivors (2.07 ± 0.62 vs 2.62 ± 0.65; P = 0.023). The non-survivors had significantly higher rates of ventilator use, history of heart disease, septic shock and lower rates of consultation with urological departments after diagnosis (P < 0.05).

CONCLUSIONS

Patients with bacteremia complicating urinary infection by P. aeruginosa have a low death rate. Earlier intervention by urologists might improve patients' outcome. Lower albumin levels, ventilator use, history of heart disease and septic shock are factors associated with higher mortality rate.

Assessment, management and prevention of urinary tract infections in men

While urinary tract infections (UTIs) are uncommon in healthy men aged under 50 years, their prevalence rises in men aged over 65 years. UTIs can be classified as uncomplicated or complicated. UTI in men is considered to be more complicated than in women, because it is often related to abnormalities of the urinary tract, such as prostatic enlargement or a urethral stricture. UTI is associated with a significant disease burden and cost to patients and healthcare organisations. It is one of the most common reasons for prescription of antibiotics in primary care; however, because antibiotic resistance is becoming increasingly widespread, it is essential that these drugs are used prudently. The main strategy for preventing UTIs in men is to avoid the use of indwelling catheters.

Comparison between non-septic and septic cases in stone-related obstructive acute pyelonephritis and risk factors for septic shock: A multi-center retrospective study

PURPOSE

This study assessed risk factors for septic shock in patients with obstructive acute pyelonephritis (APN) associated with upper urinary tract calculi in a multi-center retrospective study.

METHODS

We studied 143 patients admitted to 4 hospitals in Japan with obstructive APN associated with upper urinary tract calculi. Data on gender, age, hypertension, diabetes, neurological disease or malignant disease, laboratory data (white blood cell (WBC) and C-reactive protein (CRP)), drainage, and bacterial strains including Escherichia coli in the non-septic and septic groups were collected. Risk factors for septic shock were analyzed by univariate and multivariate statistical analyses.

RESULTS

There were a total of 107 non-septic cases (74.8%) and 36 septic cases (25.2%). The commonest strains of urinary tract infection-causative bacteria were E. coli in the non-septic group (23 cases, 21.5%) and septic group (13 cases, 36.1%) (p > 0.05). Emergency drainage was administered in 74.8% of the non-septic group and 97.2% of the septic group (p > 0.05). Meropenem was most often used as the initial treatment in the non-septic group (20 cases, 18.7%) and septic group (22 cases, 61.1%) (p < 0.0001). Risk factors for septic shock in multivariate analyses were diabetic mellitus (odds ratio (OR) = 3.591, p = 0.0098) and CRP ≥ 10 (OR = 1.057, p = 0.0119) as significant independent factors in this multicenter study.

CONCLUSIONS

APN is a common infectious disease, especially in the cases with urinary tract obstruction where patients easily acquire bacteremia or sepsis. Stone-associated obstructed APN can cause fatal septic shock in cases with diabetes and CRP ≥ 10. Further prospective studies will be undertaken to draw definitive conclusions.

Prevention and management of urosepsis triggered by ureteroscopy

Urosepsis is a potentially life-threatening phenomenon that may occur after an ureteroscopic procedure. With the increasingly widespread adoption of ureteroscopy, there is a concern that the rates of urosepsis may increase. This review examines the current work being undertaken to minimize postprocedure infections both in the field of device development and in clinical care. Guidelines for the diagnosis and management of urosepsis will be discussed.

Evaluation of the BacterioScan 216Dx for Standalone Preculture Screen of Preserved Urine Specimens in a Clinical Setting

Background

The BacterioScan 216Dx laser microbial growth monitoring system was evaluated as an option for preurine culture screening of preserved urine specimens at an acute care medical center.

Methods

The BacterioScan 216Dx system performance characteristics and the economic impact (cost effectiveness) for the laboratory were assessed. Urinalysis performance compared to urine culture was assessed if urinalysis was ordered as part of the patient care set.

Results

When compared to urine culture, the BacterioScan had an overall performance with corresponding 95% confidence intervals of 76% (68-83) sensitivity, 84% (80-87) specificity, 55% (48-63) positive predictive value, and 93% (90-95) negative predictive value for 610 randomly selected preserved urine specimens. Urinalysis compared to urine culture overall performance was 59% (48-69) sensitivity, 87% (83-90) specificity, 53% (43-63) positive predictive value, 89% (86-92) negative predictive value for 414 urine specimens.

Conclusions

While the system did improve the turnaround time to a negative report, adoption of the BacterioScan system would increase the reagent budget for laboratory urine culture by 2.34 times the current cost, potentially making BacterioScan prohibitive in a budget restricted environment. Additionally, performance when compared to traditional urine culture was less than acceptable for a diagnostic laboratory to use as a stand-alone urinary tract infection screen.

Impact of an antimicrobial stewardship program on urinary tract infections caused by extended-spectrum β-lactamase-producing Escherichia coli

OBJECTIVE

To analyze the clinical and economic impact of an antimicrobial stewardship program (ASP) targeting urinary tract infections (UTI) caused by extended-spectrum β-lactamase (ESBL)-producing Escherichia coli.

METHODS

An observational retrospective study that included adults with a diagnosis of UTI caused by ESBL-producing E. coli admitted to a tertiary care hospital in Barcelona, Spain, between January 2014 and December 2015. The impact of the ASP was analyzed in terms of clinical and economic outcomes.

RESULTS

A total of 222 patients met the inclusion criteria and an intervention was made by the ASP team in 104 cases (47%). ASP intervention was an independent variable related to clinical cure (p = 0.008). Other variables influencing clinical outcomes were the McCabe Jackson score (p = 0.005) and outpatient status (p < 0.001). The ASP interventions in this study had no economic impact.

CONCLUSIONS

Antimicrobial stewardship has a positive clinical impact on UTIs caused by ESBL-producing E. coli. Further prospective studies are needed to assess the economic impact of ASPs on UTI caused by ESBL-producing E. coli.

Bilateral renal abscessation and chronic active pyelonephritis in a male camel (Camelus dromedarius) caused by Escherichia coli

This report summarizes the clinical, hematobiochemical, ultrasonographic, histopathological and bacteriological findings in a male Arabian camel (Camelus dromedarius) with bilateral renal abscessation and chronic active pyelonephritis. Owner complaint included a decreased appetite and loss of body condition with occasionally voiding red urine. In the right kidney, ultrasonographic changes included a hypoechoic fluid surrounding the renal parenchyma. Within the left kidney, a large volume of hypoechoic contents were imaged. Bacteriological examination yielded only Escherichia coli. To the authors’ knowledge this is the first reported case of bilateral renal abscessation and chronic active pyelonephritis in dromedary camels. In conclusion, renal ultrasonography provides a precise and non-invasive technique for diagnosis and subsequent clinical decision making of renal abscessation and chronic pyelonephritis camels.