Urinary tract infections

Urinary tract infections (UTIs) are still the precipitating cause for 7 million patient visits per year with total costs exceeding one billion dollars. Diagnostic modalities have become more "friendly" for the smaller laboratory with "dip stick" culture tests providing a rapid method of isolation of pathogens. In many cases, empiric therapy is more cost effective than culture in uncomplicated UTIs in women. The etiologic organisms implicated in UTIs have not changed dramatically over the past two decades, with E. coli still accounting for the majority of cases. Antibiotic susceptibility patterns have changed dramatically, with ampicillin losing utility die to the emergence of resistance. Quinolones, which have been exceedingly active against gram-negative enteric pathogens, are no longer universally active and more pathogenic organisms, such as pseudomonas, may be resistant. The emergence of other highly resistant organisms, such as Enterococcus faecium, must be watched for.     

Urinary tract infections may trigger relapse in multiple sclerosis

Multiple Sclerosis (MS), a demyelinating disease of the central nervous system, is the most common neurological disease affecting young adults in North America and, in the majority of cases, is associated with accumulating disability. Urinary tract dysfunction affects up to 90% of the MS population, and urinary tract infections are encountered in up to 74% of the tested population. Viral infections have previously been shown to trigger acute exacerbation and it is our experience that urinary tract infection also commonly precedes relapse, and, when recurrent, is associated with neurologic progression. We present three case studies from our MS Clinic where recurrent UTI was associated with acute exacerbation and neurologic progression refractory to intravenous steroid treatment. Interferons, protein signaling molecules, have recently been found to play a role in acute exacerbation and disease progression in individuals with MS. Viral infections induce interferon release which may activate T cells to produce gamma-interferon. Interferon-gamma precipitates relapse and stimulates production of tumour necrosis factor-alpha, a cytokine directly toxic to oligodendrocytes. Bacterial infections similarly induce interferon release and may activate immune pathways that result in MS exacerbation and neurologic progression.     

Urinary tract infections in infants, an insidious clinical picture

Three boys aged 4, 5 and 7 weeks drank poorly, vomited and were lethargic. There were metabolic disorders attributable to a urinary tract infection. Ultrasonography revealed anatomical anomalies. After antibiotic treatment and, if necessary, surgical correction, the patients recovered. Follow-up was uncomplicated except persisting polyuria in one of the patients. A urinary tract infection in young children is difficult to recognise because of the aspecific presenting symptoms. It can cause a severe metabolic disturbance in which hyponatraemia and hyperkalaemia develop (pseudohypoaldosteronism), combined with metabolic acidosis and polyuria. A high alertness for urinary tract infections in young children with these aspecific symptoms is needed as well as metabolic and urologic evaluation.     

Urinary tract infections in the first three months following kidney transplantation

Eighty kidney transplants were examined. During the first three months following transplantation, urinary tract infections occurred in 68 patients (85%). Fifty patients (74%) have had a few episodes of infections in the form of either suprainfection or recurrence whereas in the remaining patients there was only one episode of urinary infection. No difference in infection incidence was noted in both men and women. Ninety percent of urinary infections occurred within the first 4 weeks following transplantation. The most frequent cause of the urinary tract infections were gram-negative bacilli of Enterobacteriaceae family. In case of multiple infections there was a high percentage of gram-positive cocci.     

Urinary tract infections and pregnancy in women who underwent antireflux surgery in childhood

PURPOSE: For several decades ureteroneocystostomy has been performed in children to correct primary vesicoureteral reflux. A purported indication for antireflux surgery is to prevent significant upper urinary tract infection during pregnancy. We performed a long-term followup of women who underwent antireflux surgery during childhood to determine outcome in regard to urinary tract infection history and pregnancy. MATERIALS AND METHODS: We identified 227 women of childbearing age who underwent ureteral reimplantation for primary vesicoureteral reflux from 1964 through 1981. Of the 122 women contacted 41 had been pregnant (77 total pregnancies). Cystitis or asymptomatic bacteriuria and pyelonephritis developed during 18 and 5 pregnancies, respectively. The 77 pregnancies resulted in 57 term births, 7 voluntary pregnancy interruptions and 13 spontaneous abortions. RESULTS: Patients who previously underwent successful antireflux surgery continued to have a significant number of urinary tract infections through the intervening years. Despite a higher than expected incidence of pyelonephritis, they had relatively little hypertension and renal insufficiency. During pregnancy the incidence of pyelonephritis was only slightly higher than that of the general population. However, severe complications of pregnancy, such as preeclampsia, premature birth and acute renal failure, occurred more frequently in women with a history of renal scarring or hypertension (7 of 12) than in those with a history of recurrent infection alone (3 of 10). CONCLUSIONS: When renal scarring is present, reflux should be corrected before pregnancy to minimize maternal and fetal morbidity. When scarring is not present, the literature suggests that women with a history of reflux are at increased risk for pyelonephritis during pregnancy whether or not ureterocystostomy was performed. Pregnant women with a history of reflux may benefit from prophylactic antibiotics and women with reflux nephropathy should be followed throughout life.     

Urinary tract infections in girls: the cost-effectiveness of currently recommended investigative routines

Current recommendations for the universal investigation of urinary tract infection (UTI) in children by ultrasonography, voiding cystourethrography, and dimercaptosuccinic acid renal scan (and sometimes intravenous pyelography as well) are not based on any convincing evidence as to the necessity or effectiveness of such a routine. Over 8% of all girls will have a UTI during childhood. About 87 individuals in a million will develop end-stage renal disease (ESRD) by the age of 60 years, caused in about 9% by pyelonephritis (PN) or reflux nephropathy. From these statistics, the maximal risk of a first diagnosed UTI progressing to ESRD is approximately 1:10,000. The risk of developing hypertension following a first UTI in childhood, without eventual evolution to ESRD, appears to be very small. The cost of the widely recommended routine imaging procedures ranges from U.S. $355 in Britain to U.S. $1,090 in the United States. The minimal cost of preventing a single progression to ESRD by early diagnosis of underlying pathology-if this were possible in all cases-would range between U.S. $5 million in Britain and U.S. $15 million in the United States. Since in many instances progressive renal damage can not be prevented, the true cost is considerably higher. Lower UTI in girls is a very common and, in most cases, benign finding in primary-care practice. It is suggested that girls with afebrile UTI, presenting with lower urinary tract symptoms alone, need not undergo any imaging procedures, but should be followed with urine examinations and cultures at the time of febrile illness. The recommended investigative routines should be reserved for UTI in infants and in girls with fever or other symptoms suggesting PN, and for proven recurrent UTI. Such a regimen will allow a marked saving in terms of costs and in terms of unnecessary radiation, psychological stress to children, and stress, inconvenience, and time loss to parents. There is no evidence that this approach will compromise the course or final outcome of this very common condition.     

Urinary tract infections in children due to Pseudomonas aeruginosa in Enugu, Nigeria

Ileal duplication cysts within a giant omphalocele are very rare. Only a few cases have been reported in the English literature (4). We report one case of giant omphalocele, which included a huge ileal duplication cyst, detected by prenatal US, and diagnosed at surgery after birth. This case illustrates the diagnostic and therapeutic problems occurring during pregnancy and the neonatal period.     

Urinary tract infections in children: why they occur and how to prevent them

Urinary tract infections (UTIs) usually occur as a consequence of colonization of the periurethral area by a virulent organism that subsequently gains access to the bladder. During the first few months of life, uncircumcised male infants are at increased risk for UTIs, but thereafter UTIs predominate in females. An important risk factor for UTIs in girls is antibiotic therapy, which disrupts the normal periurethral flora and fosters the growth of uropathogenic bacteria. Another risk factor is voiding dysfunction. Currently, the most effective intervention for preventing recurrent UTIs in children is the identification and treatment of voiding dysfunction. Imaging evaluation of the urinary tract following a UTI should be individualized, based on the child's clinical presentation and on clinical judgment. Both bladder and upper urinary tract imaging with ultrasonography and a voiding cystourethrogram should be obtained in an infant or child with acute pyelonephritis. Imaging studies may not be required, however, in older children with cystitis who respond promptly to treatment.     

Urinary tract cancer and isoniazid

A case control study was conducted in Washington County, Md. to assess the possibility that isoniazid might be associated with the production of malignant neoplasms of the urinary tract. One hundred and forty-two cases of bladder cancer and 48 cases of renal cancer were found in the follow-up of a 1963 census population. Each case was matched to two other persons of the same race, sex, and age enumerated in the census. The tuberculosos register for the county was searched to see whether any case or control subject had ever received isoniazid. Two members of the entire study group had a record of isoniazid administration; both were control subjects. No evidence was found to associate isoniazid with cancers of the urinary tract.     

Urinary tract injuries during obstetric intervention

A retrospective case record review of obstetric urinary tract injury in the Grampian region from 1976 to 1993 identified 16 cases of bladder injury (0.1 per 1000 deliveries, 1.4 per 1000 caesarean sections and four cases of ureteric injury (0.03 per 1000 deliveries, 0.27 per 1000 caesarean sections). Diagnosis of bladder injury was immediate, but of ureteric injury often delayed. Although the injury rates are lower than previously reported and previously reported risk factors not confirmed, this audit has resulted in guidelines for junior staff, compliance with which will be monitored, and every case of urinary tract injury will be reviewed.     

Urinary tract obstruction in polycystic renal disease

The incidence and cause of urinary tract obstruction in 100 consecutive patients with polycystic renal disease are reported. Because of nonspecific symptoms, poor renal function, and calyceal distortion, obstruction may be difficult to detect. A number of patients had infundibular obstruction caused by a calculus, clot, or inflammation and edema of the pelvocalyceal wall.