Recurrent Purulent Triaditis in a Patient with Congenital X-linked Agammagiobullnemia

A patient with congenital x-linked agammaglobulinemia, who had two separate episodes of an apparent bacterial purulent hepatic triaditis in the absence of any known local predisposing factors, is presented. These episodes may reflect the increased susceptibility of an immunodeficient patient to bacterial infections. This case demonstrates the need to consider hepatic involvement in the work-up of fevers of undetermined origin in immunodeficient patients, even in the absence of any radiologic or sonographic evidence of mechanical biliary tract obstruction.     

Uncomplicated Urinary Tract Infection

Uncomplicated urinary tract infection presenting as cystitis or pyelonephritis is common and a significant cause of ill health, although there are generally few sequelae. Unfortunately, the vast body of research now accumulating on predisposing factors and bacterial virulence has had little therapeutic consequence. Nevertheless, standardisation of diagnostic criteria and formulation of guidelines on treatment will go some way to limit the anarchy of excessive investigation and over-treatment which has hitherto contributed to rising antibiotic resistance rates. Truly effective alternative treatments and prophylactic vaccines have yet to be developed.     

Pediatric Urinary Tract Infection

Urinary tract infection (UTI) in childhood affects many children but it can be difficult to diagnose, especially in infancy where it is believed that most renal damage occurs. UTI can point the way to underlying congenital abnormalities of the urinary tract which are uncommon, as are the long-term sequelae of renal scarring, hypertension and chronic renal failure. It is now appreciated that many infants have reflux associated damage before birth with associated renal dysplasia. Investigations in children with a UTI remain controversial with ultrasonography being sufficient in experienced hands and only selected patients undergoing cystography and radionuclide imaging. Gross vesicoureteric reflux (VUR) is rare and most mild to moderate VUR resolves spontaneously. Although there is no randomised controlled trial to date low dose prophylactic antibiotics are used in the majority of children in whom VUR is detected with surgery being reserved for those with problematical infections or anatomical abnormalities. Familial reflux is increasingly recognised.     

Update in Adult Urinary Tract Infection

Urinary tract infection remains a common problem for many populations. Recent studies have expanded our understanding of the host innate immune response and its role in the familial association observed for recurrent uncomplicated urinary tract infection in healthy women. Therapeutic management for uncomplicated infection has been compromised by increasing antimicrobial resistance, particularly global dissemination of the CTXM-15 extended spectrum β-lactamase (ESBL) producing Escherichia coli ST-131 strain. Prevention strategies exploring non-antimicrobial approaches continue to show limited promise, and approaches to limit empiric antimicrobials are now being explored. For complicated urinary tract infection, increasing antimicrobial resistance limits therapeutic options for many patients. In addition to ESBL producing E. coli, NDM-1 E. coli and Klebsiella pneumoniae and other resistant Gram negatives, such as Acinetobacter species, are being isolated more frequently. There has been renewed interest in catheter-acquired urinary tract infection, the most common health–care associated infection, with several recent evidence-based guidelines for infection prevention available. However, technologic progress in development of adherence-resistant catheter materials remains disappointing.     

Recurrent Urinary Tract Infections in Kidney Transplant Recipients

Urinary tract infections (UTIs) are the most common infectious complication after kidney transplantation (KT). Recurrent UTIs after KT can contribute to increased morbidity and may also be associated with graft loss and mortality. Though several risk factors like female gender, diabetes mellitus, presence of ureteric stents, native kidney disease with urological malformations and re-transplantation have been associated with recurrent UTIs after KT, vesicoureteric reflux appears to be a unique risk factor in this patient population. The emergence of drug-resistant pathogens as causative agents for post-transplant recurrent UTIs poses a significant therapeutic challenge. The use of pathogen-specific antibiotic therapy guided by culture and sensitivity data is warranted. The optimal duration of antimicrobial therapy for recurrent UTIs in renal transplant recipients remains uncertain.     

Recurrent Urinary Tract Infections Associated with Gynecological Disorders

Recurrent urinary tract infections (UTIs) in women are defined as three or more infections in a 12-month period. They occur commonly and often have a significant impact on quality of life. Although the etiology is multifactorial (including genetic, behavioral, anatomic, and hormonal factors), certain gynecological conditions, such as uterovaginal prolapse with dysfunctional voiding, have a higher disposition to causing UTIs. The clinical evaluation must therefore be comprehensive and include a detailed medical history, a thorough physical and gynecological examination, a full urinalysis including microbiological culturing of the specimen, and appropriate imaging. Antibiotics remain the mainstay of therapy for acute UTIs and also have a role in treatment of recurrent UTIs. Prophylactically, they can be given continuously using a low-dose formula or in the form of self-start treatment or immediately postcoitus. Other useful prophylactic measures include topical estrogen in postmenopausal women and cranberry products. Emergent therapies, such as immunization and probiotics, have a promising future, but their role has yet to be defined.     

Urinary Tract Infection in Diabetes: Epidemiologic Considerations

The epidemiology of urnary tract infections (UTIs) among men and women with diabetes is similar to the epidemiology of those without: Women have greater risk than men, and frequency of sexual activity is a risk factor. The bacteriology and antibiotic susceptibility patterns also do not, in general, differ from those without diabetes. Although persons with diabetes are more likely to have asymptomatic bacteriuria, asymptomatic bacteriuria does not lead to increased risk of symptomatic infection, except during pregnancy or prior to genital-urinary or gastrointestinal surgery, and should not be treated otherwise. However, diabetes doubles the risk of UTI. The source of this increase is not well understood, although bladder dysfunction, which increases with duration of diabetes, and glycosuria are hypothesized mechanisms. As treatment using sodium glucose cotransporter 2 inhibitors—which lead to glycosuria—increases, there is a potential for the frequency of UTI to increase among those with diabetes.     

Clinical Effects of Polymyxin B Hemoperfusion in Patients With Septic Shock Caused by Urinary Tract Infection

Direct hemoperfusion with polymyxin B‐immobilized fiber (PMX‐DHP) has been widely used for severe sepsis and septic shock. However, data are limited regarding the clinical experience and efficacy of PMX‐DHP for septic shock resulting from urinary tract infection (UTI). At our institution, 15 patients with septic shock resulting from a UTI received PMX‐DHP from January 2013 to July 2017. The cause of the urosepsis was mainly obstructive pyelonephritis secondary to ureterolithiasis or neurogenic bladder. Average Acute Physiology and Chronic Health Evaluation II (APACHE II) and Sequential Organ Failure Assessment (SOFA) scores were 25.9 ± 4.3 and 10.5 ± 2.2, respectively. If patients were still hypotensive after initial resuscitation, we began PMX‐DHP. Mean arterial pressure increased significantly from 58.3 ± 9.6 mm Hg to 93.6 ± 14.8 mm Hg just after PMX‐DHP and to 94.7 ± 16.9 mm Hg (P < 0.0001) 24 h after the treatment. Catecholamine index decreased significantly from 20.7 ± 11.3 to 9.3 ± 13.5 (P = 0.0001) 24 h after the treatment. Of 15 patients, 14 (93.3%) had survived 28 days after admission. Our results suggest a possible role for PMX‐DHP in the rapid stabilization of hemodynamics in patients with septic shock with an underlying UTI. These patients may be good candidates for PMX‐DHP.     

Diagnosis and Management of Urinary Tract Infection in Hospitalized Older People

OBJECTIVES: To compare the diagnosis and management of urinary tract infection (UTI) in hospitalized older people with clinical criteria and therapeutic guidelines.
DESIGN: A retrospective case series of emergency hospital admissions collected over an 18-month period.
SETTING: An acute general hospital in northwest England.
PARTICIPANTS: Two hundred sixty-five patients aged 75 and older with a diagnosis of UTI at hospital discharge.
MEASUREMENTS: Data relating to age, sex, presenting complaint, admission and discharge destinations, background comorbidities and medications, investigations performed, treatment given, length of stay, and complications were obtained using chart review.
RESULTS: Of the 265 patients (mean age 85.4) the overdiagnosis of UTI was common, with 43.4% of patients not meeting criteria. Only 32.1% of patients overall had any urinary tract symptoms (48.7% in the UTI group). Of the non-UTI group, 12 (10.4%) had urinary tract symptoms with a negative urine culture, 43 (37.4%) had asymptomatic bacteriuria (ASB), and 60 (52.2%) had neither urinary tract symptoms nor bacteriuria. Treatment given varied greatly. The mortality rate was 6.0%, and the average length of stay was 29.9 days (median 17.0, range 1–192). Complications were frequent, including Clostridium difficile diarrhea (8%), falls (4%), methicillin-resistant Staphylococcus aureus infection (3%), and fracture (2%).
CONCLUSION: More-reliable criteria are needed to aid the diagnosis of UTI in hospitalized older people. Better adherence to clinical management guidelines may improve outcomes.     

Inhaled Long-acting Anticholinergics and Urinary Tract Infection in Individuals with COPD

Inhaled, long-acting anticholinergic medication (LAA), commonly used for moderate-to-severe chronic obstructive pulmonary disease (COPD), has been shown to decrease COPD hospitalizations, emergency department visits, and acute exacerbations but has also been associated with urinary tract infection (UTI) in a prior meta-analysis. The objective of this study was to verify if there was an association between LAA and UTI in older individuals with COPD. A population-based, real-world cohort study using health administrative data from Ontario, Canada was conducted. Incidence of UTI was compared between older people with physician-diagnosed COPD, who were new users of inhaled long-acting anticholinergics and new users of inhaled corticosteroids–a reference medication used in similar clinical settings that has no known association with UTI. Propensity score matching was used to minimize the effects of confounding. An overall association between LAA and various measures of UTI in older individuals was not found. However, in a priori defined stratified analyses, men newly initiated on LAA were 75% more likely to develop a UTI than men newly started on an inhaled corticosteroid (hazard ratio 1.75; 95% confidence interval 1.05–2.92). No significant association was seen in women. In conclusion, older men with COPD newly started on LAA are at increased risk of UTI. Men considering an inhaled LAA should be informed of this risk and, if they decide to take it, be provided with appropriate monitoring.