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.

Pyuria as an independent predictor of intravesical recurrence after radical nephroureterectomy in patients with upper tract urothelial carcinoma.

PURPOSE: About one-third of patients who undergo radical nephroureterectomy (RNUx) for upper tract urothelial carcinoma (UTUC) experience intravesical recurrence (IVR). This study investigated whether pyuria is a feasible predictor of IVR after RNUx in patients with UTUC. MATERIALS AND METHODS: Seven hundred forty-three patients with UTUC who underwent RNUx at a single institute were analyzed in this study. The participants were divided into two groups: those without pyuria (non-pyuria) and those with pyuria. Kaplan-Meier survival analysis was performed, and p-values were assessed using the log-rank test. Cox regression analyses were performed to identify the independent predictors of survival. RESULTS: The pyuria group had a shorter IVR-free survival period (p=0.009). The five-year IVR-free survival rate was 60.0% in the non-pyuria group vs. 49.7% in the pyuria group according to the Kaplan-Meier survival analysis. After the multivariate Cox regression analysis, pyuria (hazard ratio [HR]=1.368; p=0.041), a concurrent bladder tumor (HR=1.757; p=0.005), preoperative ureteroscopy (HR=1.476; p=0.013), laparoscopic surgery (HR=0.682; p=0.048), tumor multiplicity (HR=1.855; p=0.007), and a larger tumor (HR=1.041; p=0.050) were predictors of risk for IVR. There was no association between pyuria and recurrence-free survival (p=0.057) or cancer-specific survival (p=0.519) in the Kaplan-Meier survival analysis. CONCLUSIONS: This study concluded that pyuria was an independent predictor of IVR in patients with UTUC after RNUx.

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).

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.

Pyuria in Children with Diabetic Ketoacidosis.

Acute kidney injury occurs frequently during pediatric diabetic ketoacidosis (DKA). We reviewed urinalyses from 561 children with DKA; pyuria was detected in 19% overall and in 40% of children with more comprehensive urine testing (≥3 urinalyses) during DKA.

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.

Fever, abdominal pain, and adnexal mass.

A CT scan pointed to a surgical emergency. But what surgeons found was not the small bowel obstruction they were expecting.

Rare case of post-varicella membranoproliferative glomerulonephritis presenting with massive proteinuria.

Chicken pox caused by varicella zoster virus is usually a self-limiting disease causing rare life-threatening complications. Involvement of the kidneys is infrequent during the course of the illness. Literature shows rare reports of acute glomerulonephritis following varicella infection. We report a case of 16-year-old boy presenting with anasarca with characteristic healed rashes of chicken pox. His urinalysis revealed a 'massive' nephrotic range proteinuria (16 g/24 hours), gross hematuria and pyuria. A percutaneous renal biopsy showed membranoproliferative glomerulonephritis. Most cases of post-varicella glomerulonephritis have been described in children, massive proteinuria of this range in an immunocompetent adolescent, being an extremely rare entity. Acute proliferative glomerulonephritis in such cases is usually an immune complex hypocomplementaemic glomerulonephritis in response to the zoster infection. Proteinuria in most patients is benign and self-limiting with few fatal reports of crescentic glomerulonephritis progressing to acute renal failure.

Comparison of Different Rectal Cleansing Methods for Reducing Post-Procedural Infectious Complications After Transrectal Ultrasound-Guided Prostate Biopsy.

PURPOSE: To compare the efficacy of three different rectal cleansing methods for reducing post-procedural infectious complications after transrectal ultrasound (TRUS)-guided prostate biopsy. MATERIALS AND METHODS: A total of 451 consecutive patients who underwent TRUS-guided prostate biopsy were prospectively included in this study. All patients received targeted antimicrobial prophylaxis and underwent bowel preparation through laxative administration. The patients were divided into three groups on the basis of the method of rectal cleansing immediately before the procedure. Group I patients (n=165) underwent cleansing of the perianal skin using povidone-iodine cotton balls; group II patients (n=116) received an injection of povidone-iodine solution (0.1 g/mL) into the anal and lower rectal canals; and group III patients (n=170) received direct manual cleansing of the mucosal surface of the anus and lower rectum using povidone-iodine cotton balls. The three groups were compared regarding the incidence of post-procedural infectious complications, re-hospitalization rates, and mean length of hospital stay using one-way ANOVA, the Chi-square test, and multiple logistic regression analysis. RESULTS: Post-procedural infectious complications occurred in 21.8%, 11.2%, and 6.5% of groups I, II, and III, respectively (P < .001). The incidence of overall infectious complications was significantly lower in group II (95% CI: 0.232-0.958, OR = 0.472, P = .038) and group III (95% CI: 0.129-0.555, OR = 0.267, P < .001) than in group I. Re-hospitalization rates were 9.7%, 2.6%, and 0.6% in groups I, II, and III, respectively (P < .001). The incidence of re-hospitalization was significantly lower in group II (95% CI: 0.070-0.869, OR = 0.247, P = .029) and group III (95% CI: 0.007-0.421, OR = 0.055, P = .005) than in group I. The mean length of hospital stay was significantly longer in group I than in group III (P = .009). CONCLUSION: Combined with targeted antimicrobial prophylaxis, direct manual cleansing of the mucosal surface of the anus and lower rectum using povidone-iodine cotton balls was most effective in preventing post-procedural infectious complications among the three different rectal cleansing methods.

Non-invasive discrimination of acute focal bacterial nephritis with pyelonephritis.

BACKGROUND: The appropriate antimicrobial treatment period for febrile urinary tract infection (UTI) can be changed, depending on whether the patient has acute focal bacterial nephritis (AFBN). The aim of this study was to clarify the characteristics of AFBN compared with those of acute pyelonephritis (APN) and establish a strategy to detect AFBN. METHODS: A total of 77 patients diagnosed with febrile UTI were enrolled. They were divided into APN (n = 64) and AFBN groups (n = 13). The clinical data and other laboratory biomarkers were retrospectively analyzed. RESULTS: The time required for fever resolution after antimicrobial treatment was significantly longer in the AFBN group than in the APN group (2.77 days vs 1.11 days, respectively, P < 0.001). Also, the time to disappearance of pyuria after antimicrobial treatment was longer in the AFBN group than in the APN group (6.22 days vs 2.32 days, respectively, P = 0.001). Fever lasting >1.75 days after antimicrobial treatment had a sensitivity of 92% and specificity of 79% for the detection of AFBN, while pyuria disappearance after 4 days had a sensitivity of 88% and specificity of 85%. When patients fulfilled both cut-offs, the sensitivity and specificity were 89% and 97%. CONCLUSION: Acute focal bacterial nephritis was associated with fever of significantly longer duration after antimicrobial treatment, and it took a longer time for pyuria to disappear. Children with febrile UTI should be evaluated for AFBN if the fever persists ≥48 h after the initiation of antimicrobial treatment and if pyuria lasts for 4 days.

The relationship between the severity of pain and stone size, hydronephrosis and laboratory parameters in renal colic attack.

OBJECTIVE: In this study, we investigated the relationship between the severity of pain level and hydronephrosis, hematuria and pyuria presence in the acute renal colic attack and whether there was a correlation between the stone size and inflammatory markers. METHODS: The patients' pain scores determined by Visual Analog Scale (VAS), CRP, WBC and NLR levels from the laboratory results, hematuria and pyuria presence in the urine analysis and hydronephrosis presence in the imaging methods were recorded. Moreover, stone size was measured for the patients for whom computed tomography (CT) method was applied. RESULTS: Mean age of the 275 patients was 41.0 ±â€¯14.9 and 61.1% of them were male. The patients' mean VAS score was 73.3 ±â€¯16.5.The mean VAS score of the groups of which hematuria and pyuria were positive and which have hydronephrosis finding was statistically higher than those whose were negative. The mean stone size was 5.2 ±â€¯2.1 mm, and those with signs of hydronephrosis on their CT (n = 66) were 5.4 ±â€¯2.3 mm, while those with no signs of hydronephrosis (n = 57) were 4.9 ±â€¯1.7. No statistical difference was found in stone size between patients with hydronephrosis and those without. Not any correlations were determined between the stone size and VAS pain score of the cases. CONCLUSIONS: We detected that the pain level was not correlated with the stone size and big stones were not statistically riskier in the hydronephrosis development. However, we think that the risk of complications such as hydronephrosis is higher in the patients whose pain level are higher and the infection may be accompanied by this group.

Predictors of low disease activity and clinical remission following belimumab treatment in systemic lupus erythematosus.

OBJECTIVES: To identify predictors of low disease activity and clinical remission following belimumab treatment in SLE. METHODS: SLE patients who received belimumab 10 mg/kg (N = 563) in the BLISS-52 and BLISS-76 clinical trials were surveyed. The performance of baseline factors in predicting attainment of low disease activity (defined as Lupus Low Disease Activity State) or clinical remission [defined as clinical (c)SLEDAI-2K = 0] at week 52 from treatment initiation was evaluated using logistic regression. Organ damage was assessed using the SLICC/ACR Damage Index (SDI). RESULTS: We demonstrated a negative impact of established organ damage on attainment of Lupus Low Disease Activity State [SDI > 0; odds ratio (OR): 0.44; 95% CI 0.22, 0.90; P = 0.024] and the primary Lupus Low Disease Activity State condition, i.e. SLEDAI-2K ⩽ 4 with no renal activity, pleurisy, pericarditis or fever (SDI > 1; OR: 0.46; 95% CI 0.27, 0.77; P = 0.004); cognitive impairment/psychosis was found to mainly account for the latter association. Baseline SDI scores > 1 predicted failure to attain cSLEDAI-2K = 0 (OR: 0.53; 95% CI 0.30, 0.94; P = 0.030), with cutaneous damage mainly driving this association. Anti-dsDNA positivity increased (OR: 1.82; 95% CI 1.08, 3.06; P = 0.025) and cardiovascular damage reduced (OR: 0.13; 95% CI 0.02, 0.97; P = 0.047) the probability of attaining cSLEDAI-2K = 0 along with a daily prednisone equivalent intake restricted to ⩽7.5 mg. CONCLUSION: Belimumab might be expected to be more efficacious in inducing low disease activity and clinical remission in SLE patients with limited or no organ damage accrued prior to treatment initiation. Patients with positive anti-dsDNA titres might be more likely to achieve clinical remission along with limited or no CS use.

Urothelial carcinoma of the upper urinary tract: preoperative pyuria is not correlated with bladder cancer recurrence and survival.

OBJECTIVE: To identify the impact of preoperative pyuria on the bladder cancer recurrence and survival of patients who were treated surgically for UTUC. PATIENTS AND METHODS: Study included 319 consecutive patients who were treated with RNU for UTUC. Cox proportional hazard regression models were used to evaluate the association of preoperative pyuria with outcome. RESULTS: Eighty patients (25.1%) had pyuria. Preoperative pyuria was associated with sex (P = 0.01), tumor focality (P = 0.01), tumor size (P = 0.05), tumor stage (P = 0.01), lymph node metastasis (P = 0.01), lymphovascular invasion (P = 0.02), and chemotherapy (P = 0.04). A total of 102 patients recurred, with a median time to bladder recurrence of 24.2 months. Bladder cancer recurrence-free survival rates for these 319 patients at 1, 3, 5, 7, and 10 years were 84.6, 72.4, 69.0, 68.3, and 68.0%, respectively. Preoperative pyuria was not independently associated with bladder cancer recurrence (HR 1.15; p = 0.5). Preoperative pyuria was associated with OS (HR 1.57; p = 0.02) and CSS (HR 1.65; p = 0.02). However, preoperative pyuria was not independently associated with OS and CSS (HR 1.07; p = 0.79). CONCLUSIONS: Preoperative pyuria is unable to predict outcomes in a single-centre series of consecutive patients who were treated with RNU.

Thrombocytosis as a Predictor of Serious Bacterial Infection in Febrile Infants.

BACKGROUND: Most of the febrile infants <90 days old will have no more than a mild viral infection but there is a substantial minority that will be diagnosed as having serious bacterial infection at a reported prevalence of 10-14%. A simple, readily available, inexpensive diagnostic marker that yields results quickly and also accurately identifies bacterial infections in febrile infants would be of great value in management of these infants. This study aims to assess the role of thrombocytosis in predicting serious bacterial infection in young febrile infants beyond neonatal period. METHODS: A hospital based cross-sectional observational study was conducted from May 2016 to April 2017 on 76 febrile infants of age group 29-90 days in Kanti Children's Hospital. RESULTS: The incidence of serious bacterial infection was found 43 (56.6%). Thrombocytosis, elevated C-reactive protein and pyuria were significantly higher in serious bacterial infection cases (p value <0.05). Thrombocytosis alone had the sensitivity of only 53.5%, but had specificity of 90.9%. Elevated C-reactive protein had the best sensitivity (81.4%). Combination of leukocytosis, elevated C-reactive protein, pyuria and thrombocytosis had better sensitivity (93.0%) than these parameters alone. The overall ability of platelet count to identify infants with SBI was only moderate (AUC: 0.722). Elevated C-reactive protein was found to have better ability to identify infants with serious bacterial infection (AUC: 0.846). CONCLUSIONS: Thrombocytosis is a common finding in young infants diagnosed with serious bacterial infection. It has however, moderate ability in identifying infants with serious bacterial infection. Combining thrombocytosis with elevated C-reactive protein, leukocytosis and pyuria has better sensitivity in diagnosing serious bacterial infection than these individual parameters alone. Hence, combining these parameters may help in early prediction of febrile young infants at risk of serious bacterial infection.

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.

Early features of Kawasaki disease with pyuria in febrile infants younger than 6 months.

BACKGROUND: Children with Kawasaki disease (KD) and pyuria have been misdiagnosed with urinary tract infection (UTI). We compared clinical and laboratory features at admission between two groups of infants under 6 months of age who showed initial pyuria, to identify the initial clues suggestive of KD. METHODS: We retrospectively reviewed the medical records of children with fever who were under 6 months of age with pyuria, over a 10-year period (2007-2017). We included infants with sterile pyuria who were finally diagnosed with KD and those with UTI. RESULTS: During the period investigated, 12 (9.9%) KD patients with sterile pyuria and 378 infants with UTI were included in this study. Older age (P < 0.01), a longer duration of fever; total and before admission (P < 0.01), more negative nitrite test (P < 0.01), higher platelet count (P = 0.04), increased C-reactive protein (CRP) (P < 0.01) and erythrocyte sedimentation rate (ESR) (P < 0.01), were identified as initial features of infants finally diagnosed with KD. In the receiver operating characteristic analysis, optimal cut-off values of 509 k/µL for platelet count, 60 mg/L for CRP, and 68 mm/H for ESR were selected. Patients with ESR > 68 mm/hr had a ninefold higher odds of KD compared to those with lower ESR levels (odds ratio: 8.963, 95% confidence intervals: 1.936-41.493, P = 0.005), whereas CRP and platelet count could not significantly increase in the odds of KD at a cut-off point. CONCLUSION: Persistent fever, elevated ESR, and negative urine nitrite test can serve as early clues to suspect KD in febrile infants with pyuria.