Current Pyuria Cutoffs Promote Inappropriate Urinary Tract Infection Diagnosis in Older Women.

BACKGROUND: Pre-existing lower urinary tract symptoms (LUTS), cognitive impairment, and the high prevalence of asymptomatic bacteriuria (ASB) complicate the diagnosis of urinary tract infection (UTI) in older women. The presence of pyuria remains the cornerstone of UTI diagnosis. However, >90% of ASB patients have pyuria, prompting unnecessary treatment. We quantified pyuria by automated microscopy and flowcytometry to determine the diagnostic accuracy for UTI and to derive pyuria thresholds for UTI in older women. METHODS: Women ≥65 years with ≥2 new-onset LUTS and 1 uropathogen ≥104 colony-forming units (CFU)/mL were included in the UTI group. Controls were asymptomatic and classified as ASB (1 uropathogen ≥105 CFU/mL), negative culture, or mixed flora. Patients with an indwelling catheter or antimicrobial pretreatment were excluded. Leukocyte medians were compared and sensitivity-specificity pairs were derived from a receiver operating characteristic curve. RESULTS: We included 164 participants. UTI patients had higher median urinary leukocytes compared with control patients (microscopy: 900 vs 26 leukocytes/µL; flowcytometry: 1575 vs 23 leukocytes/µL; P < .001). Area under the curve was 0.93 for both methods. At a cutoff of 264 leukocytes/µL, sensitivity and specificity of microscopy were 88% (positive and negative likelihood ratio: 7.2 and 0.1, respectively). The commonly used cutoff of 10 leukocytes/µL had a poor specificity (36%) and a sensitivity of 100%. CONCLUSIONS: The degree of pyuria can help to distinguish UTI in older women from ASB and asymptomatic controls with pyuria. Current pyuria cutoffs are too low and promote inappropriate UTI diagnosis in older women. Clinical Trials Registration. International Clinical Trials Registry Platform: NL9477 (https://trialsearch.who.int/Trial2.aspx?TrialID=NL9477).

Asymptomatic Bacteriuria and Pyuria in Premenopausal Women.

BACKGROUND: Asymptomatic bacteriuria and pyuria in healthy women often trigger inappropriate antimicrobial treatment, but there is a paucity of data on their prevalence and persistence. METHODS: To evaluate the prevalence and persistence of asymptomatic bacteriuria and pyuria in women at high risk of recurrent urinary tract infection, we conducted an observational cohort study in 104 healthy premenopausal women with a history of recurrent urinary tract infection with daily assessments of bacteriuria, pyuria, and urinary symptoms over a 3-month period. RESULTS: The mean age of participants was 22 years, and 74% were white. Asymptomatic bacteriuria events (urine cultures with colony count ≥105 CFU/mL of a uropathogen on days with no symptomatic urinary tract infection diagnosed) occurred in 45 (45%) women on 159 (2.5%) of 6283 days. Asymptomatic bacteriuria events were most commonly caused by Escherichia coli, which was present on 1.4% of days, with a median duration of 1 day (range, 1-10). Pyuria occurred in 70 (78%) of 90 evaluable participants on at least 1 day and 25% of all days on which no symptomatic urinary tract infection was diagnosed. The positive predictive value of pyuria for E. coli asymptomatic bacteriuria was 4%. CONCLUSIONS: In this population of healthy women at high risk of recurrent urinary tract infection, asymptomatic bacteriuria is uncommon and, when present, rarely lasts more than 2 days. Pyuria, on the other hand, is common but infrequently associated with bacteriuria or symptoms. These data strongly support recommendations not to screen for or treat asymptomatic bacteriuria or pyuria in healthy, nonpregnant women.

Assessment of Significant Bacteriuria, Bacterial Profile and Pyuria among Pregnant Women with Urinary Tract Symptoms in Enugu, South-Eastern Nigeria: A Cross-Sectional Study.

BACKGROUND: Urinary tract symptoms are common in pregnancy; thus, symptom-based diagnosis of urinary tract infection (UTI) might not be accurate. Such women are often exposed to antibiotics without urine culture and antibiotics sensitivity. Identification of pyuria on urine microscopy of pregnant women with urinary tract symptoms may predict significant bacteriuria and guide such women's treatment in under-resourced settings. METHODS: A cross-sectional study of 233 consecutive consenting pregnant women with UTI symptoms at theantenatal clinic of the University of Nigeria Teaching Hospital ItukuOzalla, Nigeria. Participants' mid-stream urine specimens were sent for microscopy, culture, and antibiotics sensitivity. Data analysis was descriptive and inferential at 95% confidence level. RESULTS: The prevalence of symptomatic UTI among pregnant women with urinary tract symptoms was 33.5% (78/233). Coliform bacilli were the most common isolates (82.0%) from participants' urine. Ceftriaxone and ampicillin-cloxacillin had the highest (76.9%) and least (12.8%) sensitivity, respectively. Using urine culture as the standard, pyuria on microscopy showed a sensitivity of 43.6% and a specificity of 93.5% for predicting symptomatic UTI. CONCLUSION: The prevalence of UTI among pregnant women with urinary tract symptoms was low, and the most common isolate was coliform bacilli. Though pyuria had reasonably good accuracy for diagnosing symptomatic UTI, it should not be used for this purpose because of the risks associated with misdiagnosis.

CONTEXTE: Les symptômes des voies urinaires sont fréquents pendant la grossesse; ainsi, le diagnostic basé sur les symptômes de l'infection des voies urinaires (IVU) pourrait ne pas être exact. Ces femmes sont souvent exposées à des antibiotiques sans culture d'urine ni sensibilité aux antibiotiques. L'identification de la pyurie par microscopie urinaire chez les femmes enceintes présentant des symptômes des voies urinaires peut prédire une bactériurie importante et orienter le traitement de ces femmes dans les milieux défavorisés. BUT: Déterminer la prévalence des infections urinaires chez les femmes enceintes présentant des symptômes des voies urinaires et évaluer l'exactitude de la pyurie pour prédire les infections urinaires symptomatiques pendant la grossesse à Enugu, au Nigéria. MÉTHODES: Une étude transversale de 233 femmes enceintes consentantes consécutives présentant des symptômes d'infection urinaire à la clinique prénatale de l'hôpital universitaire d'Ituku, à Ozalla, au Nigéria. Les échantillons d'urine à mi-parcours des participants ont été envoyés pour microscopie, culture et sensibilité aux antibiotiques. L'analyse des données était descriptive et inférentielle à un niveau de confiance de 95. RÉSULTATS: La prévalence des infections urinaires symptomatiques chez les femmes enceintes présentant des symptômes des voies urinaires était de 33,5% (78/233). Les bacilles coliformes étaient les isolats les plus courants (82,0%) des urines des participants. La ceftriaxone et l'ampicilline-cloxacilline avaient respectivement la sensibilité la plus élevée (76,9%) et la moins élevée (12,8%). En utilisant la culture d'urine comme norme, la pyurie à la microscopie a montré une sensibilité de 43,6% et une spécificité de 93,5% pour prédire les infections urinaires symptomatiques. CONCLUSION: La prévalence des infections urinaires chez les femmes enceintes présentant des symptômes des voies urinaires était faible et l'isolat le plus courant était les bacilles coliformes. Bien que la pyurie ait une précision raisonnablement bonne pour diagnostiquer une infection urinaire symptomatique, elle ne doit pas être utilisée à cette fin en raison des risques associés à un diagnostic erroné. MOTS CLÉS: Grossesse, infection symptomatique des voies urinaires, culture d'urine, microscopie d'urine.

How Testing Drives Treatment in Asymptomatic Patients: Level of Pyuria Directly Predicts Probability of Antimicrobial Prescribing.

BACKGROUND: Urinalysis is a readily available test often used for screening. Pyuria is a common finding in asymptomatic patients; however, it is unknown how often identification of pyuria in the absence of confirmatory cultures leads to antimicrobial prescribing. The objective of this study was to measure the association between pyuria and antimicrobial initiation during the perioperative period and assess harms versus benefits of treatment. METHODS: A retrospective cohort of preoperative patients within the national healthcare system during the period 1 October 2008-30 September 2013 who had a urinalysis performed during the 30-day preoperative period was created; patients with positive urine cultures were excluded. The primary exposure was pyuria on preoperative urinalysis. The primary outcome was antimicrobial initiation. Secondary outcomes included postoperative surgical site (SSI), urinary tract (UTI), and Clostridioides difficile infections. Trend and logistic regression analyses were performed. RESULTS: Among 41 373 patients, 3617 had pyuria. 887 (24.5%) patients with pyuria received antimicrobials versus 1918 (5.1%) patients without pyuria. As the degree of pyuria increased, the odds of receiving antimicrobials also increased linearly (low, 14.7%; moderate, 24.0%; high pyuria, 37.4%). Preoperative pyuria was associated with postoperative C. difficile infections (aOR, 1.7; 95% CI, 1.2-2.4); risk was higher in patients who received antimicrobials (aOR, 2.4; 1.7-3.4). Pyuria was not associated with SSI but was associated with increases in UTI after orthopedic and vascular procedures; this risk was not mitigated by antimicrobial therapy. CONCLUSIONS: Urine screening during the preoperative period is a low-value intervention that increases antimicrobial exposure but does not improve postoperative outcomes.

Assessment of asymptomatic bacteriuria and sterile pyuria among antenatal attendants in hospitals in northern Ghana.

BACKGROUND: Asymptomatic bacteriuria (ASB) and sterile pyuria (SP) are complexities of UTI whose prevalence are not known in the northern sector of Ghana. Our aim was to determine the occurrence of sterile pyuria and asymptomatic bacteriuria among pregnant women accessing antenatal care at a secondary and tertiary care hospitals in Tamale, northern Ghana. METHODS: A cross sectional study was conducted by screening 530 pregnant women with no signs of acute urinary tract infection attending antenatal clinic for a period of 6 months. Midstream urine was collected for microscopy, quantitative urine culture and antibiotic susceptibility testing. Data analysis was carried out using the Statistical Package for Social Sciences version 20. RESULTS: Asymptomatic bacteriuria was respectively 20 and 35.5% at Tamale Central and Tamale Teaching Hospital out of the 390 and 90 women screened. Sterile pyuria was found among 66% of the 50 women presenting at Tamale Central Hospital. More than 64% of isolates recovered from ASB patients were S. aureus and coagulase negative Staph. (CoNS). Escherichia coli was the dominant species among members of the enterobacteriaceae isolated. Highest susceptibility was recorded against gentamicin and amikacin while most resistance was to Ampicillin, cotrimoxazole, chloramphenicol and nitrofurantoin. Resistance to imipenem and vancomycin were 28.8 and 52%, with strains showing multiple drug resistance of between 81 and 92%. CONCLUSION: The prevalence of asymptomatic bacteriuria is appreciably higher (20-35.5%) than documented rates in the southern sector of the country. The presence of sterile pyuria which may be an indication of asymptomatic renal impairment and most often overlooked in antenatal management is 66%. Empirical treatment of UTIs at the Tamale Central and Teaching Hospital without confirmation of susceptibility may result in treatment failure. It is necessary to screen and treat pregnant women for ASB and SP due to the complications associated with these conditions.

Relationship between post-void residual urine volume, preoperative pyuria and intravesical recurrence after transurethral resection of bladder carcinoma.

OBJECTIVES: To evaluate the relationship between residual urine volume, pyuria and bladder carcinoma recurrence. METHODS: The clinical data of 305 patients who had post-void residual urine volume measured and preoperative pyuria were retrospectively collected. The patients were classified into three risk groups based on the presence of residual urine and pyuria: good (negative residual urine and pyuria), intermediate (positive residual urine or pyuria) and poor (positive residual urine and pyuria). Predictive factors for intravesical recurrence-free survival were statistically analyzed using Cox proportional hazard models and Kaplan-Meier methods. The propensity score matching method was used to adjust the patients' backgrounds. RESULTS: The median follow-up period for all patients was 44 months. The presence of residual urine (P = 0.0164) and pyuria (P = 0.0233) were two independent prognostic factors for recurrence. After patients were classified into risk groups, the poor-risk group showed significantly shorter recurrence-free survival compared with that of the good- (P = 0.0002) and intermediate-risk groups (P = 0.0090). Even after matching, the presence of residual urine was related to short recurrence-free survival in male patients (P = 0.0012). When stratified by European Organization for Research and Treatment of Cancer risk groups, the presence of pyuria was related to short recurrence-free survival, especially for intermediate-risk patients without bacillus Calmette-Guérin treatment. CONCLUSIONS: Post-void residual urine and preoperative pyuria are two risks for recurrence-free survival in non-muscle-invasive bladder cancer.

Microscopic Bacteriuria Detected by Automated Urinalysis for the Diagnosis of Urinary Tract Infection.

OBJECTIVE: To evaluate the test performance of microscopic bacteriuria by automated urinalysis for presumptive urinary tract infection (UTI) in young children. STUDY DESIGN: This is a retrospective cross-sectional study of children aged <2 years evaluated for UTI in a single large emergency department with paired automated microscopic urinalysis and culture. Test characteristics were calculated for automated microscopic bacteriuria and pyuria, and a practical diagnostic threshold of bacteriuria was determined. Standard test performance measures and receiver operator characteristic curves were generated. The diagnostic performance of bacteriuria was compared with microscopic pyuria. RESULTS: Two thousand five hundred fifty-four children with a median age of 6.1 months were studied, 19% of whom had a positive urine culture. Automated microscopic bacteriuria ≥1+ resulted in a positive likelihood ratio (LR+) of 4.5 (95% CI, 3.9-5.2) and negative LR (LR-) of 0.52 (95% CI, 0.47-0.57). Pyuria alone (≥5 WBC/high-power field) had a LR+ of 4.5 (95% CI, 4.1-5.0) and a LR- of 0.14 (95% CI, 0.11-0.18), whereas the addition of automated microscopic bacteriuria ≥1+ improved the LR+ to 16.3 (95% CI, 12.6-21.1) but raised the LR- to 0.51 (95% CI, 0.47-0.56). Test performance of automated microscopic bacteriuria measured by area under the curve analysis was lower (0.73; 95% CI, 0.70-0.76) than for pyuria (0.92; 95% CI, 0.90-0.93). Isolated automated microscopic bacteriuria without pyuria occurred in only 204 patients (8.0%), among whom only 20 (9.8%) had a positive urine culture. CONCLUSIONS: Microscopic bacteriuria measured by automated urinalysis augments the diagnostic value of pyuria for identifying presumptive UTI in young children aged <2 years. Bacteriuria is diagnostically inferior to microscopic pyuria, and in children with bacteriuria without pyuria, presumptive UTI is unlikely.

Pyuria and Urine Cultures in Patients with Acute Renal Colic.

BACKGROUND: Renal colic caused by stone(s) is common in the emergency department. Often, urinalysis reveals white blood cells, but it is unknown how frequently pyuria is sterile or infectious. OBJECTIVES: We sought to determine the incidence of pyuria in patients with renal colic and to correlate the incidence with a positive urine culture. METHODS: A 1-year retrospective review of adult patients with renal colic presenting to three community emergency departments was performed. Patients without confirmed renal stone(s) or completed urinalysis were excluded. Hematuria is defined as ≥5 red blood cells per high power field (RBC/HPF) and pyuria as >10 white blood cells per high power field (WBC/HPF). A positive urine culture is defined as >100,000 colony forming units per milliliter. Student's t-test, chi square, or Fisher's exact tests were performed as appropriate, with significance set at 0.05. RESULTS: There were 339 patients who satisfied the inclusion and exclusion criteria, and 14.2% of these patients had associated pyuria. There were 153 (45.1%) urine cultures performed, and 16 (10.5%) were positive. Patients with pyuria were more likely to have a positive urine culture (36.4% vs. 3.3%, respectively; p < 0.001). The percentage of positive urine cultures increased (p < 0.001) with increasing pyuria from 9.1% (10-20 WBC/HPF) to 60.0% (>50 WBC/HPF). Positive cultures also increased (p < 0.001) with increased leukocyte esterase observed on macroscopic samples, from 1.6% (small or less leukocyte esterase) to 77.8% (large-volume leukocyte esterase). CONCLUSION: Pyuria was found in 14.2% of patients with renal colic. Patients with pyuria had 36.4% positive cultures compared to 3.3% of patients without pyuria. The degree of pyuria or leukocyte esterase was significantly associated with the risk of a positive culture. Urine cultures are recommended for all patients with renal colic and pyuria.

Asymptomatic group B streptococcal bacteriuria among pregnant women in Saudi Arabia.

This study aims to determine the asymptomatic bacteriuria in pregnancy due to GBS and its antimicrobial sensitivity pattern for planning strategy for the management of these cases and also to determine the relationship between asymptomatic bacteriuria and pyuria. A total of 3863 consecutive urine specimens were collected from 3863 pregnant women with asymptomatic bacteriuria attending the obstetrics and gynaecology department of our hospital over a period of two years. Specimens were processed using standard microbiological procedures. All the subjects were evaluated for bacteriuria. The prevalence of asymptomatic bacteriuria due to group B streptococci (GBS) was 82/3863 (2.1%) among pregnant women in Saudi Arabia. Among these, 69/82 patients (84.2%) had clinical and microbiological features consistent with cystitis, versus 13/82 (15.8%) for pyelonephritis. About 51.2% (42/82) of the patients who had urine analysis performed had positive results based on positive urinary leucocyte esterase and pyuria. Disc-diffusion analysis of all 82 GBS isolates showed that they were highly susceptible to Augmentin and linezolid. Screening for bacteriuria in pregnancy and proper treatment must be considered as an essential part of antenatal care in this community. To prevent asymptomatic bacteriuria complications, all pregnant women should be screened at the first antenatal visit. A negative test for pyuria is not a reliable indicator of the absence of asymptomatic bacteriuria in pregnant women. Further, ongoing surveillance and evaluation of outcomes in pregnancies complicated by GBS bacteriuria is required to optimise maternal and newborn care.

Asymptomatic pyuria and bacteriuria are not risk factors for urinary tract infection in women with type 2 diabetes mellitus initiated SGLT2 inhibitors.

PURPOSE: Asymptomatic pyuria and bacteriuria are more prevalent in diabetic patients and may be associated with urinary tract infection (UTI). The aim of this study is to investigate the association between asymptomatic pyuria/bacteriuria at the initiation of SGLT2 inhibitor and UTI risk in female patients with type 2 diabetes. METHODS: The study was designed as a practical, single-center, prospective, cohort study. The female outpatients with type 2 diabetes initiated SGLT2 inhibitor were included. Patients who were symptomatic or treated in the past 3 months for urinary or genital tract infection, had a high risk for UTI were excluded. Hospitalization/antibiotic use for indications other than UTI were exclusion criteria during follow-up. All patients were followed up for 3 months. Pyuria and bacteriuria were exposure and, UTI was the outcome. Cumulative incidence and relative risk of UTI were analyzed for pyuria and bacteriuria. RESULTS: 143 female patients were included among 1132 female type 2 diabetic patients. 13 patients were excluded during follow-up. 41.5% of the patients (n = 54) had pyuria and 28.5% (n = 37) had bacteriuria. The cumulative incidence of UTI was 20% in the whole cohort, 25,9% (n = 14/54) in the pyuria group and 18.9% (n = 7/37) in the bacteriuria group. The relative risk of UTI was 1.64 (95% CI: 0.82-3.26, p = 0.15) for pyuria, 0.92 (95% CI: 0.42-2.01, p = 0.84) for bacteriuria, and 1.2 (95% CI: 0.47-3.08, p = 0.69) for pyuria plus bacteriuria. Adjusted odd ratios revealed similar results. CONCLUSIONS: Asymptomatic pyuria/bacteriuria at the initiation of SGLT2 inhibitors are not risk factors for UTI in women with type 2 diabetes.

Microbial colonization and ureteral stent-associated storage lower urinary tract symptoms: the forgotten piece of the puzzle?

PURPOSE: Ureteral stents are frequently associated with side effects. Most patients suffer from storage lower urinary tract symptoms (LUTS). Storage LUTS are commonly attributed to the irritation of the trigone, smooth muscle spasm or a combination of factors. The relationship between microbial ureteral stent colonization (MUSC) and de novo or worsening storage LUTS has not been investigated yet. METHODS: Five hundred ninety-one polyurethane ureteral stents from 275 male and 153 female patients were prospectively evaluated. The removed stents were sonicated to dislodge adherent microorganisms. Urine flow cytometry was performed to detect pyuria. A standardized urinary symptom questionnaire was given to all patients. RESULTS: Thirty-five per cent of male and 28% of female cases showed de novo or worsened storage LUTS. MUSC was more common in patients with storage LUTS compared to patients without storage LUTS (men: 26 vs. 13%, respectively, P < 0.05; women: 63 vs. 48%, respectively, P = 0.13). Pyuria was significantly more common in patients with storage LUTS compared to patients without storage LUTS (men: 55 vs. 40%, respectively, P < 0.05; women: 70 vs. 45%, respectively, P < 0.05). No significant correlation was observed between the detected genera of microorganisms and storage LUTS. CONCLUSIONS: Our data show a significant association between MUSC- and stent-related de novo experienced or worsened storage LUTS in men. The incidence of MUSC is most common in both female and male patients with storage LUTS and accompanying pyuria. In these patients, a combination of antibiotics and anti-inflammatory drugs may be regarded as treatment option.

Chronic asymptomatic pyuria precedes overt urinary tract infection and deterioration of renal function in autosomal dominant polycystic kidney disease.

BACKGROUND: Urinary tract infection (UTI) occurs in 30%-50% of individuals with autosomal dominant polycystic kidney disease (ADPKD). However, the clinical relevance of asymptomatic pyuria in ADPKD patients remains unknown. METHODS: We retrospectively reviewed medical records of 256 ADPKD patients who registered to the ADPKD clinic at Seoul National University Hospital from Aug 1999 to Aug 2010. We defined the asymptomatic pyuria as more than 5-9 white blood cells in high-power field with no related symptoms or signs of overt UTI. Patients were categorized into 2 groups depending on its duration and frequency: Group A included non-pyuria and transient pyuria patients; Group B included recurrent and persistent pyuria patients. The association between asymptomatic pyuria and both the development of overt UTI and the deterioration of renal function were examined. RESULTS: With a mean follow-up duration of 65.3 months, 176 (68.8%) out of 256 patients experienced 681 episodes of asymptomatic pyuria and 50 episodes of UTI. The annual incidence of asymptomatic pyuria was 0.492 episodes/patient/year. The patients in group B showed female predominance (58.5% vs. 42.0%, P=0.01) and experienced an upper UTI more frequently (hazard ratio: 4.612, 95% confidence interval: 1.735-12.258; P=0.002, adjusted for gender and hypertension). The annual change in estimated glomerular filtration rate (ΔeGFR) was significantly larger in magnitude in group B than in group A (-2.7±4.56 vs. -1.17±5.8, respectively; P=0.01). Age and Group B found to be the independent variables for ΔeGFR and developing end-stage renal disease (16.0% vs. 4.3%, respectively; P=0.001). CONCLUSIONS: Chronic asymptomatic pyuria may increase the risk of developing overt UTI and may contribute to declining renal function in ADPKD.

Prevalence of signs of lower urinary tract disease and positive urine culture in dogs with diabetes mellitus: A retrospective study.

BACKGROUND: No recent studies have evaluated the association between clinical signs of lower urinary tract disease (LUTD) and positive urine culture in dogs with diabetes mellitus. OBJECTIVE: Determine the prevalence of subclinical bacteriuria (ie, positive urine culture without signs of LUTD) in dogs with diabetes mellitus. ANIMALS: One hundred seven dogs with diabetes mellitus were evaluated at a university veterinary hospital. METHODS: Retrospective study evaluating diabetic dogs with a single sample paired urinalysis and urine culture. Relationship between the presence of signs of LUTD, pyuria, and bacteriuria and urine culture results were compared using Fisher exact testing. RESULTS: Fifteen dogs (14%) had a positive urine culture via cystocentesis or free catch, of which 8 (53%) had pyuria, and 4 (27%) had signs of LUTD. Of the 88 dogs (82%) without signs of LUTD, 11 (13%) had a positive culture. A significant association was found between a positive urine culture and pyuria (OR infinity; 95% CI 20.34-infinity, P < .00001) and bacteriuria (OR infinity; 95% CI 164.4-infinity, P < .00001). No association was found between urine culture results and signs of LUTD (OR 1.87; 95% CI 0.59-6.85, P = .46). CONCLUSION AND CLINICAL IMPORTANCE: Subclinical bacteriuria occurred in this cohort of dogs, and our findings reinforce the recommendation that urine cultures should not be routinely performed in diabetic dogs particularly if pyuria and bacteriuria are absent.

A new model to assist decision-making of optimal antibiotics duration for treating asymptomatic bacteriuria or pyuria prior to retrograde intrarenal surgery.

BACKGROUND: The aim of this study was to establish a model that predicts postoperative fever and enables decision-making regarding optimal antibiotic therapy duration for asymptomatic bacteriuria or pyuria prior to retrograde intrarenal surgery (RIRS). METHODS: We retrospectively investigated 667 consecutive patients with asymptomatic bacteriuria or pyuria who underwent RIRS between September 2016 and December 2019. We constructed a predictive nomogram for risk quantification of postoperative infection. A preoperative score model was used for risk stratification. The effect of antibiotic therapy duration (short-course [2-3 days] vs. long-course [≥4 days]) was evaluated. RESULTS: Infections occurred in 113 (16.9%) patients. The incidence of fever was marginally lower in long-course group than in short-course group (15% vs. 19%, P=0.173). Hydronephrosis, stone size, multi-drug resistant bacteriuria, and degree of pyuria were used to construct a preoperative score model (the H-SMP score). Using the H-SMP score, the patients were stratified into low- and high-risk groups based on varying incidence rates of postoperative fever (11.0% vs. 29.9%, P<0.001). Significant reduction in fever occurred only among high-risk patients in the long-course group (23.5% vs. 38.0%, P=0.022), and no such reduction in postoperative fever rates occurred in low-risk patients (10.4% vs. 11.5%, P=0.712). Even after propensity score matching, the low-risk group showed no improvement in postoperative fever incidence with long-course antibiotic therapy (7.5% vs. 10.0%, P=0.419). CONCLUSIONS: Based on the newly developed H-SMP score, we concluded that long-course antibiotics (≥4 days) recommended in high-risk patients may not bring in more benefit in low-risk patients for treating asymptomatic bacteriuria or pyuria prior to RIRS.

Randomized clinical trial on antimicrobial prophylaxis for flexible urethrocystoscopy.

OBJECTIVES: One of the main drawbacks of flexible urethrocystoscopy is the risk of urinary tract infection (UTI). In order to reduce this risk, antimicrobial prophylaxis has been considered, however there is not a unanimous view regarding indications, dosage, type of antibiotic, and so on. To clarify this uncertainty, we practiced a pilot and experimental study aimed at assessing the effectiveness of chemoprophylaxis with 3 grams of fosfomycin trometamol in the prevention of UTI after urethrocystoscopy. METHODS: Sixty patients were entered into a pilot randomized clinical trial between March and August 2011. Thirty patients were assigned to a control group without receiving any antibiotic dose, and the intervention group (30 patients) received 3 g fosfomycin trometamol. Ten days later urine culture and sediment analysis were performed in all patients. Significant bacteriuria was considered from > 105 CFU /ml. One month later a telephone survey was developed to assess urinary symptoms, and assistance to the family doctor. We estimated the cumulative incidence of bacteriuria, pyuria and microhematuria in both groups, and we compared the results using a strategy of analysis per protocol and intention to treat. RESULTS: The incidence of bacteriuria, pyuria and microhematuria in the control group was 10%, 23.3% and 26.7% respectively and in the intervention groups the values differed depending on the type of analysis. Considering only the 27 patients (per protocol analysis), the incidence would be 11.1%, 37.0% and 29.6% respectively. If we include the three patients who did not completed the study (per intention to treat analysis) and considering their results as negative, the results were 10%, 33.3% and 26.7% respectively. Finally, in the case the three cultures not performed in this group had produced a positive result, the impact would have been 20.0%, 43.3% and 36.7%. In any of the three cases, the differences with the control group were not statistically significant. CONCLUSIONS: In a selected population and with appropriate aseptic measures, antibiotic chemoprophylaxis does not appear to show a clinically relevant reduction in the incidence of UTI in patients undergoing flexible urethrocystoscopy.

Asymptomatic bacteriuria in users of low-dose combined oral contraceptives.

OBJECTIVES: To investigate the association between oral contraceptive use and the prevalence of asymptomatic bacteriuria in women. METHODS: The study was conducted on healthy women of childbearing age who either used low-dose combined oral contraceptives (COCs; cases) or applied the withdrawal method (controls). A positive urine culture with a colony count of more than 10(5)/ml, with the same bacteria on two consecutive specimens, was defined as asymptomatic bacteriuria. Pyuria was defined as the presence of ≥ 10 leukocytes per mm3 of urine. RESULTS: Overall, 369 women in the COC group and 364 in the control group were evaluated. The mean ages of women in the COC group and of controls were 29.9 ± 5.4 years and 30.4 ± 6.0 years, respectively (p = 0.280). Asymptomatic bacteriuria was detected in 2.4% of COC users and 1.9% of the controls (p = 0.633). Pyuria was found in 16% of the cases and 18.1% of the controls (p = 0.441). None of these differences was statistically significant. There was no significant association between duration of COC usage (< 1 year vs. ≥ 1 year) and asymptomatic bacteriuria. CONCLUSION: Use of low-dose COCs (even long-term) does not increase the risk of asymptomatic bacteriuria.

Significance of pyuria in the diagnosis of urinary tract infections in neonates.

OBJECTIVES: To determine the significance of pyuria as a predictor of culture proven urinary tract infections (UTI) in neonates and to assess the frequency of urinary tract anomalies in neonates with pyuria. METHODS: Prospective study conducted at the neonatal intensive care unit of a tertiary care hospital; (Liaquat National Hospital Karachi) for a period of 4 months from April 2008 to August 2008. One hundred and ten consecutive infants < or = 28 days of age admitted to the NICU of Liaquat National Hospital for medical reasons were included in the study. Information regarding age, gender, antenatal history, birth weight, clinical examination, laboratory findings and outcome were recorded on a questionnaire. Septic work up was performed and urine samples were collected using urethral catheterization. Patients showing any number of white blood cells on microscopy were included and their urine sent for culture. All patients had Ultrasound done during their hospital stay and those patients with any renal abnormality were further investigated with Micturating cyestoretherogram (MCUG) at 6 weeks. RESULTS: Out of one hundred and ten patients admitted, thirty five patients showed the presence of pus cells in urine and were included in the study. Of the 35 neonates with pyuria, 71.4% had no growth in urine cultures and 38.2 % neonates with insignificant pyuria (< or = 9 cells in urine) showed a positive culture. The renal ultrasound was normal in 51.4% neonates with pyuria although it was abnormal in 100% of the subjects with higher number of pus cells in urine (> 20 pus cells). CONCLUSION: Pyuria is not a useful marker for the diagnosis of culture proven UTI in neonates it cannot be used as an indicator of underlying renal abnormality, though it may have some utility in neonates with > 20 /numerous pus cells.

Pyuria is not always sterile in children with Kawasaki disease.

BACKGROUND: Although Kawasaki disease (KD) often presents with sterile pyuria, bacterial pyuria (urinary tract infection [UTI]) occasionally occurs. METHODS: This was a retrospective cohort study of 285 children with KD diagnosed between 1995 and 2005. Among these patients, a total of 210 patients underwent routine urine tests and 75 children underwent urine culture tests. This study was conducted to investigate the incidence, clinical manifestations, management and outcome of KD with pyuria. RESULTS: The incidence of pyuria was 29.5% (62/210). Among the 75 children undergoing urine culture tests, 34 had sterile pyuria (45.3%), eight had bacterial pyuria (10.7%), two had UTI without pyuria (2.7%) and 31 had neither pyuria nor UTI (41.3%). When pyuria was used as a predictor of KD with UTI, the positive and negative predictive values were 19% and 93.9%, respectively. There were no significant differences in demographic data, clinical presentations, laboratory results, duration of fever, ratio of resistant KD or risk level, except in the nitrite test, between both groups. CONCLUSIONS: Pyuria was not always sterile in patients with KD. Although there was no different clinical phenotype or coronary outcome in KD patients with or without UTI, we suggest that UTI should be considered and evaluated in KD patients with pyuria, a positive nitrite test or a positive result of urine culture. If UTI is definitively diagnosed, the patient should be treated for a UTI as well as for KD and complete post-UTI work-up is recommended.

Urine markers of kidney disorders and their risk associations in HIV-infected patients attending Nyanza Provincial General Hospital in Kisumu, Western Kenya.

OBJECTIVE: To identify abnormal levels of urine metabolites and cells that serve as markers of existing kidney disorders in ambulatory HIV-infected patients. DESIGN: A cross sectional study. SETTING: Nyanza Provincial General Hospital's patient support centre. SUBJECTS: A total of 593 HIV infected patients were studied. INTERVENTION: Dipstick urinalysis test was used to screen mid stream urine to detect constituents with altered levels. RESULTS: Out of the 593 participants, the urine of 214 (36.1%) had abnormally altered levels of urine constituents, with more females afflicted than males [41.5% vs. 27.8%; OR 1.84 (1.28-2.63), chi2 = 11.08, p = 0.0009]. Urobilinogen was the most common urine metabolite while ketones were least commonly present. More participants had altered levels of leucocytes than erythrocytes in urine. Patients with pyuria were three times more likely to have elevated erythrocytes in their urine as well (chi2 = 34.37, p < 0.0001). Similarly, the risk of having proteinuria was three times higher in patients with pyuria (p < 0.0003, Fisher's test). Patients with erythrocytes in urine also had a threefold likelihood of having proteinuria (P < 0.0003, Fisher's test). Fewer ARV users had abnormal urine markers [15.7% vs 24.3% OR 0.62 (0.41-0.94), chi2 = 5.2, p < 0.05]. CONCLUSION: Metabolites and cellular markers of kidney disorders were prevalent in the urine of HIV patients especially females and those with pronounced immune depletion (CD4 counts equal to or below 500). ARVs use was associated with reduced manifestation of these markers.

Risks of repeated visits for uninvestigated dyspepsia in three community hospitals of Khon Kaen, Thailand.

BACKGROUND: Uninvestigated dyspepsia (UD) is common and only 26.4% of these are peptic ulcer disease, while 50% are non-ulcer dyspepsia. A recent study found that nephrolithiasis with urinary tract infection may have the dyspeptic symptoms. OBJECTIVE: The authors searched for any associations between repeated UD and pyuria, hematuria and other factors. MATERIAL AND METHOD: A case-control study was performed. It consisted of 489 patients with repeated UD who had visited community hospitals for at least two times per year and 489 controls sampled from the data of the subjects, free of dyspeptic symptoms, from the multi-stage random survey for subjective health complaints in the same province. Multivariate logistic regression models were used for case-control comparisons. RESULTS: By logistic regression analysis, UD was significantly associated with problems caused by purine-rich foods (PRFs), chronic fatigue, flank paresthesia, hematuria, myofascial pain, and pyuria. The respective adjusted odds ratios and 95% confidence interval (CI) were: 6.67 (4.58, 9.68), 5.06 (3.46, 7.40), 3.98 (2.41, 6.60), 2.97 (2.01, 4.38), 1.91 (1.32, 2.76) and 1.58 (1.01, 2.45). The variables of age (> 48), sex, dysuria, poly-arthralgia, headache and back pain were not significantly associated with UD. The foods that aggravated UD were bamboo shoots, fermented rice noodles, beef alcohol and insects. The rate of pyuria and hematuria was significantly increased with the number of visits within a year [p-value (Chi-square for trend), 0.015 and 0.032]. CONCLUSION: These findings indicate that pyuria, hematuria, and purine-rich foods were associated with repeated hospital visits for dyspepsia.