Reducing Catheter-Associated Urinary Tract Infections Across a Hospital System Through Urine Culture Stewardship.

Objective: To evaluate the effectiveness and safety of an evidence-based urine culture stewardship program in reducing hospital catheter-associated urinary tract infections (CAUTIs) and the rate of CAUTIs across a 3-hospital system. Patients and Methods: This is a prospective, 2-year quality improvement program conducted from October 1, 2018, to September 30, 2020. An evidence-based urine culture stewardship program was designed, which consisted of the following: criteria for allowing or restricting urine cultures from catheterized patients, a best practice advisory integrated into the ordering system of an electronic medical record, and a systematic provider education and feedback program to ensure compliance. The system-wide rates of CAUTIs (total CAUTIs/catheter days×1000), changes in intercepts, trends, mortality, length of stay, rates of device utilization, and rates of hospital-onset sepsis were compared for 3 years before and 2 years after the launch of the program. Results: Catheter-associated urinary tract infections progressively decreased after the initiation of the program (B=-0.21, P=.001). When the trends before and after the initiation of the program were compared, there were no statistically significant increases in the ratio of actual to predicted hospital length of stay, intensive care unit length of stay, system-wide mortality, and intensive care unit mortality. Although the rates of hospital-acquired sepsis remained consistent after the implementation of the stewardship program through the first quarter of 2020, the rates showed an increase in the second and third quarters of 2020. However, hospital-onset sepsis events associated with the diagnosis of a urinary tract infection did not increase after the intervention. Conclusion: Urine culture stewardship is a safe and effective way to reduce CAUTIs among patients in a large multihospital health care system. Patient safety indicators appeared unchanged after the implementation of the program, and ongoing follow-up will improve confidence in the long-term sustainability of this strategy.

Combined diagnostic modalities improve detection of detrusor external sphincter dyssynergia.

Introduction. The diagnosis of detrusor-external sphincter dyssynergia (DESD) is a clinically relevant finding during urodynamic testing. However, there is no consensus regarding diagnostic specifics of electromyography (EMG) or voiding cystourethrography (VCUG). We evaluated the concordance of the two modalities most commonly used in clinical practice for the diagnosis of DESD. Methods. Patients were prospectively evaluated by a single urodynamicist at an academic center and retrospectively re-evaluated by an independent urodynamicist for agreement. DESD was determined by increased patch EMG activity or a dilated bladder neck/proximal urethra on VCUG during detrusor contraction. Minimal acceptable criterion for agreement was set at 70%. Results. Forty-six patients were diagnosed with DESD with both modalities available. Of these 46 patients, 25 were diagnosed by both tests, 11 by VCUG alone and 10 by patch EMG alone. Binomial testing demonstrated the proportion of agreement was 54% (95% CI 39% to 68%). Conclusion. We found significant disagreement between the two modalities, similar to previously reported findings using needle EMG, and we expand the applicability of our data to the majority of clinicians who use patch EMG electrodes. This further supports the idea that the combined use of EMG and VCUG for diagnosis can identify more cases of DESD than either modality alone.

Splenda® improves tolerance of oral potassium citrate supplementation for prevention of stone formation: results of a randomized double-blind trial.

BACKGROUND AND PURPOSE: Oral citrate supplements have been shown to decrease kidney stone recurrence rates in both laboratory and clinical studies. The taste of the citrate supplements, however, is poor, and long-term compliance is low. Our objective was to determine if Splenda(®) added to potassium citrate (KCit) improves palatability without changing 24-hour urine parameters. PATIENTS AND METHODS: 12 subjects were randomly assigned to receive either KCit alone for 3 days or KCit + Splenda in a double-blind trial. The 24-hour urine collections were performed before and after 3 days of therapy. After 1 week, the two groups switched treatments. After each treatment, a visual analog taste scale was completed to gauge the taste and palatability. The 24-hour urine parameters of kidney stone risk factors were compared between groups. The primary end points were to determine whether Splenda improved palatability of citrate supplementation and whether it altered 24-hour urine parameters. RESULTS: Taste was judged to be 2.5 ± 0.9 points better in the Splenda + KCit compared with KCit alone (P=0.02). The 24-hour Cit, K, and pH were significantly higher in the KCit and KCit + Splenda groups compared with baseline, but not significantly different from each other. CONCLUSION: Splenda significantly improves the palatability of KCit therapy and does not alter the beneficial effects of KCit on 24-hour urine Cit, K, or pH. The addition of Splenda altered the average taste score from one that might prohibit compliance to one that would not.

Tonsillectomy does not improve bedwetting: results of a prospective controlled trial.

PURPOSE: Sleep disordered breathing caused by tonsillar hypertrophy has been implicated as a cause of primary and secondary nocturnal enuresis in children. We prospectively studied the preoperative and postoperative rates of nocturnal and daytime incontinence in a group of children with tonsillar hypertrophy undergoing tonsillectomy compared to a matched control group undergoing surgery unrelated to the airway or urinary tract. MATERIALS AND METHODS: A total of 326 toilet trained children 3 to 15 years old were included, with 257 in the tonsillectomy group and 69 in the control group. Severity of tonsillar hypertrophy was graded preoperatively on a scale of 1 to 4. A voiding questionnaire regarding number of bedwetting and daytime incontinence episodes per week, voids per day, bowel movements per week, secondary or primary enuresis and family history was completed by parents preoperatively, and at 3 and 6 months postoperatively. RESULTS: Preoperatively the respective rates of nocturnal enuresis and daytime incontinence were 33% and 17% in the tonsillectomy group (p=0.89), and 35% and 14% in the control group (p=0.3). The respective cure rates for bedwetting at 3 and 6 months postoperatively were 40% and 50% in the tonsillectomy group (p=0.60), and 35% and 48% in the control group (p=0.61). Similarly no difference was seen in improvement or cure of daytime incontinence at 3 and 6 months postoperatively. CONCLUSIONS: We found no association between tonsillar hypertrophy and urinary incontinence before or after tonsillectomy.

Pediatric urinary stone disease--does age matter?

PURPOSE: It has been proposed that younger children are less likely to pass renal calculi spontaneously, and that children younger than 10 years are more likely to have an identifiable metabolic abnormality and subsequently a higher risk of recurrence. We report our clinical outcomes in children with urinary calculi, specifically examining these factors. MATERIALS AND METHODS: We performed a retrospective review of all pediatric patients diagnosed with renal or ureteral calculi at our institution between 2000 and 2007. Of 150 patients evaluated and treated during this period 80 (86 stones) had sufficient followup data to be included. Patients were divided into 2 groups according to age, namely 10 years or younger and older than 10 years. There were 39 patients in the younger group and 41 patients in the older group. Stone size and location, successful passage or intervention, recurrence and 24-hour urine metabolic study results were recorded. RESULTS: Of the younger cohort stones were ureteral in 43% and renal in 57%. The opposite trend was seen in older patients, with 69% having ureteral and 31% having renal stones (p = 0.02). Mean stone size (greatest dimension) did not differ significantly between the older and younger groups (6.9 mm vs 5.5 mm, p = 0.17). Overall stone passage rate was 34% for younger and 29% for older patients (p = 0.65). No significant mean size differences in passed stones existed between the groups (3.2 mm vs 2.5 mm, p = 0.31). Overall younger vs older ureteral stone passage rate was 37% vs 41% (p = 0.58), and for renal stones it was 32% vs 0%. Stones recurred in 7 younger and 6 older patients. CONCLUSIONS: Younger children were more likely to present with renal stones, while older children had more ureteral stones. Overall children 10 years old or younger are as likely to pass stones as older children. Renal stones are more likely to be successfully managed expectantly in younger children. Metabolic abnormalities and stone recurrences are observed at similar rates between younger and older children.

Complete eversion of the urinary bladder: presentation, review, and algorithm for management.

BACKGROUND: Complete eversion of the urinary bladder is a rare problem that presents a serious management challenge. Currently no standard treatment recommendations exist for management. We describe our experience with bladder eversion and present an algorithm for treatment. CASE: An elderly, multiparous woman presented with complete bladder eversion after partial colpocleisis. Her bladder was reduced by a combined suprapubic and perineal approach with cystopexy to the anterior abdominal wall. CONCLUSION: Multiparous postmenopausal women appear to be at highest risk for complete bladder eversion. External transurethral reduction is sometimes successful, but most cases require laparotomy.

Phenytoin metabolite renal calculus: an index case.

INTRODUCTION: Drugs and their metabolites are known factors in 1% to 2% of all kidney stones. Certain antiepileptic drugs are known to cause stone formation. Phenytoin is used as a first line antiepileptic therapy for many seizure disorders. We present what we believe to be the first report of a phenytoin metabolite urinary stone. METHODS: A 79-year-old woman with a fever and seizure disorder was found to have a right pelvic kidney with hydronephrosis and multiple large calcifications. She had been taking the antiepileptic medication phenytoin for the past 10 years. Average total serum phenytoin level from the year prior was in the normal range. Free phenytoin levels were not routinely monitored, but the one value available was elevated at 5.1 ng/dL. The patient underwent a percutaneous nephrolitomy, ultimately expiring from medical complications after the procedure. Final stone analysis revealed a composition of 35% phenytoin metabolite (5-(para-hydroxyphenyl)-5-phenylhydantoin) and 65% proteinaceous material. An extensive review of literature including PubMed, MedLine, and various internet search engines was performed, searching for any prior reports of urinary calculi formed from phenytoin or its metabolite. RESULTS: No previous reports of phenytoin or phenytoin metabolite urinary stones were found in the medical literature. Phenytoin has many known ill effects on the genitourinary system including acute interstitial nephritis, nephrotic syndrome, acute renal failure, and priapism. Now we can add urinary lithiasis to the list of its potential adverse effects. This article represents the first report of a phenytoin metabolite urinary stone. CONCLUSION: A metabolite of the commonly used antiepileptic medication phenytoin can cause clinically relevant urolithiasis leading to significant morbidity and even mortality. Clinicians should have an increased level of suspicion for metabolite stone formation in symptomatic patients taking antiepileptic medications. Further studies on phenytoin metabolism and its potential for inducing urinary lithiasis should be performed.

Protein oxidation as a novel biomarker of bladder decompensation.

OBJECTIVE: To measure the degree to which partial bladder outlet obstruction (PBOO) results in oxidative bladder damage, which subcellular components of the bladder are affected and whether these changes correlate with bladder function. MATERIALS AND METHODS: In all, 32 rabbits were divided into four groups. Each group underwent PBOO for 1, 2, 4, and 8 weeks, respectively. Bladder tissue from each group was homogenized and separated into subcellular fractions via differential centrifugation. The carbonyl content within the subcellular fractions, including the nuclear, mitochondrial, and microsomal pellets, was then quantified by dot blot analysis. RESULTS: Total bladder oxidation increased with duration of obstruction across all subcellular fractions. The largest increase in total oxidation occurred between 4 and 8 weeks. Protein oxidation density in the nuclear and microsomal fractions both showed increases at 2 weeks obstruction, decreases at 4 weeks, and then large increases at 8 weeks. The increase in protein oxidation density between 4 and 8 weeks obstruction was most pronounced in the microsomal fraction. CONCLUSIONS: Overall bladder protein oxidation increased with the duration of obstruction and increased at a greater rate during the transition to decompensation. Furthermore, the subcellular fraction that exhibited the most oxidation was the microsomal pellet. The amount of protein oxidation correlated with the functional changes in the bladder.

The effect of partial bladder outlet obstruction on carbonyl and nitrotyrosine distribution in rabbit bladder.

OBJECTIVES: Recent evidence indicates that ischemia and reperfusion (free radical generation) are major etiologic factors in the rabbit bladder subjected to partial outlet obstruction. The current investigation was designed to determine the time course of damage caused by reactive oxygen species (ROS) and reactive nitrogen species (RNS) by measuring the carbonyl and nitrotyrosine content of the bladder. METHODS: Male rabbits underwent surgical partial bladder outlet obstruction for durations of 1, 2, 4, and 8 weeks. Sham-operated rabbits served as controls. The contractile responses to field stimulation (32 Hz) and carbachol (20 micromol/L) were determined. The nerve density was determined by using immunohistochemical methods. The carbonyl and nitrotyrosine contents within the bladder body wall and mucosa were analyzed by Western blotting. RESULTS: Nerve density showed marked decrease in obstructed bladders. The responses to field stimulation and carbachol showed remarkable decrease in bladders after 8 weeks' obstruction. The protein carbonylation increased significantly in obstructed bladders when compared with controls, both in mucosa and muscles and reached the highest level in 4 weeks' obstruction. There was a 2-fold increase for nitrotyrosine in mucosa after 8 weeks of obstruction. The increased expression of nitrotyrosine in muscle was maximized at 4 weeks of obstruction. CONCLUSIONS: The free radicals mediated protein carbonylation and tyrosine nitration occurs to a significant degree in the partially obstructed rabbit bladder. This may be related with sensory and contractile dysfunction and can be used as markers for free radical damage and reperfusion injury.

Cystogram may be unreliable in cases of gunshot wounds to the bladder: a case report.

INTRODUCTION: Gunshot wounds to the bladder are not uncommon; however it is unusual that a bullet come to rest within the urinary bladder. Properly performed plain film cystography is trusted as a highly sensitive tool for identifying significant bladder injuries due to both blunt and penetrating trauma. Several reports suggest that cystography may be less sensitive in cases of gunshot wounds to the bladder. METHODS: We report our recent experience with a gunshot wound to the bladder and review the use of cystography in the diagnosis of bladder injury in this setting. RESULTS: Anecdotal case reports suggest that cystography may fail to identify gunshot injuries to the bladder. No large studies have been performed to evaluate its utility in this unique trauma circumstance. CONCLUSIONS: Although reliable for the diagnosis of bladder perforation in most trauma settings, cystography may fail to diagnose a penetrating bladder injury due to a gunshot wound. High clinical suspicion based on bullet trajectory, history, and physical exam should guide the workup and treatment of such patients.

Long term partial bladder outlet obstruction induced contractile dysfunction in male rabbits: a role for Rho-kinase.

AIMS: In this study we examined the expression of Rho-kinase (ROK) isoforms in rabbit detrusor smooth muscle during the progression of partial bladder outlet obstruction and correlated them with the time course of obstruction. METHODS: Detrusor samples were obtained from bladders after 1, 2, 4, and 8 weeks of obstruction and also sham operated control rabbits. Contractile responses to field stimulation (FS) and also the smooth muscle (SM) to collagen ratio were determined in isolated bladder strips. Reverse transcriptase-polymerase chain reaction, sodium dodecyl sulfate-polyacrylamide gel electrophoresis and Western blotting were used to determine the relative levels of ROK isoform expression at the mRNA and protein levels. RESULTS: Bladder weight increased gradually and contractile responses were reduced significantly over the course of obstruction. The smooth muscle/collagen ratio increased significantly during the course of obstruction. The expression of ROKalpha increased significantly to approximately the same extent in 1-4-week obstructed groups and increased further in the 8-week obstructed group, both at the mRNA and protein levels. In contrast, there was a significant decrease in the expression of ROKbeta in the obstructed groups, which gradually decrease during the course of 1-4-week obstruction period and are slightly upregulated at the decompensated stage at 8-week obstruction. CONCLUSIONS: The change in the isoforms of ROK may be part of the molecular mechanism for bladder compensation following partial bladder outlet obstruction.

Novel biomarkers of bladder decompensation after partial bladder obstruction.

AIMS: Partial bladder outlet obstruction (PBOO) results in marked contractile, biochemical, and histological alterations in the bladder. Our aim was to determine the time course of progressive PBOO in the rabbit and to find parameters that marked the shift to decompensation. MATERIALS AND METHODS: Twenty-four rabbits were subjected to 1, 2, 4, and 8 weeks of PBOO. Sham operated rabbits served as controls. At each time period, cystometry was performed and individual bladder strips were used for contractility studies. Full-thickness sections of bladder body from each rabbit were fixed in formalin and used to determine the vascular density and nerve density. The balance of the bladder body was separated between muscle and mucosa and was analyzed for superoxide dismutase (SOD) and catalase (CAT) activities. RESULTS: Bladder weight increased progressively and all contractile responses were reduced significantly over the course of obstruction. Markedly increased bladder weight and very large bladder volumes indicated decompensation. Nerve density was marked decreased in decompensated bladders. Similarly, SOD activity in muscle decreased progressively and was markedly lower in decompensated bladders. Although CAT activity of the muscle increased after 2-4 weeks of obstruction, it decreased markedly in decompensated bladders. CONCLUSION: This study shows that prolonged PBOO causes progressive deterioration in the rabbit bladder with decompensation after 8 weeks. Markedly decreased nerve density and severely reduced SOD and CAT activities are associated with the shift from compensated to decompensated function of the bladder. They may be excellent biomarkers of decompensation.

Community associated methicillin resistant Staphylococcus aureus causing Fournier's gangrene and genital infections.

PURPOSE: We identified an emerging infectious disease of the genitoperineum caused by community associated, methicillin resistant Staphylococcus aureus. MATERIALS AND METHODS: We report our experience with severe genital infections caused by community associated, methicillin resistant S. aureus occurring in 3 individuals who lacked any of the risk factors associated with traditional methicillin resistant S. aureus infection. Two cases were limited to scrotal abscesses that required only incision and drainage plus antimicrobial therapy. To our knowledge the third case represents the first and only reported case to date of Fournier's gangrene caused by community associated, methicillin resistant S. aureus. RESULTS: The prevalence of community associated, methicillin resistant S. aureus complicated skin and skin structure infections is increasing throughout the United States and other countries. Community associated, methicillin resistant S. aureus contains unique virulence factors but retains sensitivity to various nonbeta-lactam antibiotics. Historical risk factors associated with methicillin resistant S. aureus appear not to apply to infections associated with community associated, methicillin resistant S. aureus. Infections due to the latter cause have been identified in healthy individuals of all ages, races and ethnicities. Surgical and antimicrobial approaches to management are presented. CONCLUSIONS: Community associated, methicillin resistant S. aureus infections of the genitoperineum are likely to increase in incidence, necessitating heightened awareness on the part of the urologist.