Recurrent Urinary Tract Infections Due to Bacterial Persistence or Reinfection in Women-Does This Factor Impact Upper Tract Imaging Findings?

PURPOSE: We compared the rates of upper tract imaging abnormalities of recurrent urinary tract infections due to bacterial persistence or reinfection. MATERIALS AND METHODS: Following institutional review board approval we reviewed a prospectively maintained database of women with documented recurrent urinary tract infections (3 or more per year) and trigonitis. We searched for demographic data, urine culture findings and findings on radiology interpreted upper tract imaging, including renal ultrasound, computerized tomography or excretory urogram. Patients with irretrievable images, absent or incomplete urine culture results for review, no imaging performed, an obvious source of recurrent urinary tract infections or a history of pyelonephritis were excluded from analysis. RESULTS: Of 289 women from 2006 to 2014 with symptomatic recurrent urinary tract infections 116 met study inclusion criteria. Mean ± SD age was 65.0 ± 14.4 years. Of the women 95% were white and 81% were postmenopausal. Almost a third were sexually active and none had prolapse stage 2 or greater. Of the 116 women 48 (41%) had persistent and 68 (59%) had reinfection recurrent urinary tract infection. Imaging included ultrasound in 52 patients, computerized tomography in 26, ultrasound and computerized tomography in 31, and excretory urogram with ultrasound/computerized tomography in 7. Of the total of 58 imaging findings in 55 women 57 (98%) were noncontributory. One case (0.9%) of mild hydronephrosis was noted in the persistent recurrent urinary tract infection group but it was not related to any clinical parameters. Escherichia coli was the dominant bacteria in 71% of persistent and 47% of reinfection recurrent urinary tract infections in the most recently reported urine culture. CONCLUSIONS: This study reaffirms that upper tract imaging is not indicated for bacterial reinfection, recurrent urinary tract infections. However, the same conclusion can be extended to recurrent urinary tract infections secondary to bacterial persistence, thus, questioning the routine practice of upper tract studies in white postmenopausal women with recurrent urinary tract infections and trigonitis.

Robust strand exchange reactions for the sequence-specific, real-time detection of nucleic acid amplicons.

Loop-mediated isothermal amplification (LAMP) of DNA is a powerful isothermal nucleic acid amplification method that can generate upward of 10(9) copies from less than 100 copies of template DNA within an hour. Unfortunately, although the amplification reactions are extremely powerful, real-time and specific detection of LAMP products remains analytically challenging. In order to both improve the specificity of LAMP detection and to make readout simpler and more reliable, we have replaced the intercalating dye typically used for monitoring in real-time fluorescence with a toehold-mediated strand exchange reaction termed one-step strand displacement (OSD). Due to the inherent sequence specificity of toehold-mediated strand exchange, the OSD reporter could successfully distinguish side products from true amplicons arising from templates corresponding to the biomedically relevant M. tuberculosis RNA polymerase (rpoB) and the melanoma-related biomarker BRAF. OSD allowed the Yes/No detection of rpoB in a complex mixture such as synthetic sputum and also demonstrated single nucleotide specificity in Yes/No detection of a mutant BRAF allele (V600E) in the presence of 20-fold more of the wild-type gene. Real-time detection of different genes in multiplex LAMP reactions also proved possible. The development of simple, readily designed, modular equivalents of TaqMan probes for isothermal amplification reactions should generally improve the applicability of these reactions and may eventually assist with the development of point-of-care tests.

Definition of Recurrent Urinary Tract Infections in Women: Which One to Adopt?

OBJECTIVES: The aim of this study was to systematically review the various definitions of recurrent urinary tract infection (RUTI) recommended by experts and specialty societies cited in biomedical literature. METHODS: A systematic review of RUTI in women was conducted using MEDLINE, EMBASE, and PubMed between 1966 and 2016 according to the Preferred Reporting Items for Systematic Review and Meta-Analyses Statement. Twenty-five publications were selected for inclusion in this analysis. RESULTS: From review of included publications, 14 definitions of RUTI were obtained. Each source was searched for a textual definition of RUTI as well as presence or absence of specific key elements including urinary symptoms, colony forming unit count, bacterial species, number of UTIs per year, interval time between infections and a negative intervening culture. All data were reviewed by 2 separate investigators. The definition of RUTI was found highly variable in the literature. The tallying of key elements in included definitions suggests that a minimum RUTI definition should include urinary symptoms, urine culture colony forming unit/mL threshold, differentiation of bacterial persistence versus reinfection by bacterial species, and number of UTIs per year. CONCLUSIONS: This review of major RUTI definition recommendations by expert individuals and specialty societies underlines the lack of uniformity and the need for a more robust and generally agreeable RUTI definition for use in clinical and academic practice.

Impact of Allergy and Resistance on Antibiotic Selection for Recurrent Urinary Tract Infections in Older Women.

OBJECTIVES: To review the impact of antibiotic allergy and resistance in older women with recurrent urinary tract infections (RUTIs) as determinants for a suitable oral antibiotic treatment choice. METHODS: A prospectively maintained database of women 65 years old and older with documented RUTIs (≥3 UTI/y) and trigonitis on cystoscopy was reviewed. Demographic data, known drug allergies, renal function, antibiotic susceptibility of most recent urine culture, allergy, or resistance to trimethoprim-sulfamethoxazole (TMP-SMX), fluoroquinolones, and nitrofurantoin were obtained. RESULTS: From 2006 to 2014, 86 women with RUTIs met study criteria. Mean age was 77.9 ± 7.8, with 94% being Caucasian. An estimated glomerular filtration rate >30 mL/min was noted in 94%. The percentage of women allergic, resistant, or both allergic and resistant to TMP-SMX was 33%, 29%, and 15%, to fluoroquinolones was 14%, 34%, and 8.1%, or nitrofurantoin was 16%, 14%, and 5%, respectively. Twenty-eight percent (24 of 86) of women who were allergic and/or resistant to TMP-SMX and fluoroquinolones were sensitive to nitrofurantoin. Twenty percent (17 of 86) were allergic and/or resistant to all 3 antibiotics. Women who were allergic or resistant to TMP-SMX had a significantly higher number of other antibiotic resistances compared with women sensitive to TMP-SMX (4.9 ± 3.6 vs 2.1 ± 2.3; P < .0001). Similarly, women with fluoroquinolone allergy or resistance had significantly more antibiotic resistances than those who were fluoroquinolone sensitive (5.8 ± 3.5 vs 2.3 ± 2.5; P < .0001). CONCLUSION: Because of allergy and/or antibiotic resistance, several first-line antibiotics are not available for many older women with RUTIs. In nearly a third of women, nitrofurantoin was the only viable alternative.

Bladder Prolapse Configuration on Baseline Standing Cystogram Can Predict Anterior Vaginal Wall Suspension Procedure Outcomes.

OBJECTIVE: To evaluate whether bladder prolapse shape on lateral voiding cystourethrogram (VCUG) is an accurate predictor of anterior vaginal wall suspension (AVWS) procedure outcomes. METHODS: Following an institutional review board approval, preoperative lateral standing VCUG views from a prospectively maintained database of women who underwent AVWS for stage ≥2 cystocele were reviewed retrospectively by 3 reviewers. Patients with no retrievable preoperative VCUG imaging were excluded. Only the straining view with a fixed bladder volume of 125 cc was used for this project. Cystocele shape on imaging was scored as either (1) "round," (2) "crescent," or (3) not readable (suboptimal image quality or excessive artifact from prosthesis). A subset of cases was rescored by each reviewer for intra-rater reliability analysis. Intra- and inter-rater reliability was calculated using the weighted kappa coefficient (κ). Cystocele shape was correlated with the published long-term clinical outcomes after AVWS of these same women, with failure defined as prolapse recurrence stage >2 clinically or reoperation for prolapse (Kaplan-Meier). RESULTS: Between 1997 and 2013, 79 women met the study criteria. All 3 reviewers had moderate to high intra-rater reliability (κ = 1.00, 0.82, and 0.79). Inter-rater reliability among the 3 reviewers was significant (κ = 0.76), with 81% (64 out of 79) ratings in perfect concordance and 19% (15 out of 79) with 1 reviewer discordance. Prolapse recurrence-free probability between round- and crescent-shaped cystoceles was statistically significant (P = .0304). CONCLUSION: Bladder prolapse shape on baseline standing VCUG can be used to predict AVWS outcomes, with round-shaped cystoceles faring better with this vaginal native tissue repair procedure.