A case of secondary pseudohypoaldosteronism that presented as poor weight gain.

Key clinical message: Pseudohypoaldosteronism (PHA) carries a good prognosis if treated early and appropriately, but some cases can have life-threatening events. We underscored the need to consider secondary PHA as one of the differential diagnoses of hyponatremia and hyperkalemia in infancy. Abstract: Pseudohypoaldosteronism (PHA) type 1 has two classifications; the primary type, caused by genetic abnormalities that develop during neonatal and infancy periods, and the secondary type, caused by urinary tract malformation and urinary tract infection. Secondary PHA, if treated early and appropriately, has a good prognosis; however, some cases can present life-threatening events. Therefore, early diagnosis is crucial. We present a case of early infancy secondary PHA presented with marked hyponatremia and poor weight gain. The patient's growth and development improved with secondary PHA treatment. Here, were demonstrated the value of prompt action against infection and electrolyte imbalance and the importance of imaging for diagnosis, and underscore the need to consider secondary PHA as a differential diagnoses of hyponatremia and hyperkalemia in infancy. However further studies, including basic research, to elucidate the diseases pathology is warranted.

Paediatric Escherichia coli urinary tract infection: susceptibility trends and clinical management-a retrospective analysis of a 10-year period.

BACKGROUND: Escherichia coli is the predominant urinary pathogen in children. Irish and international studies have demonstrated increasing antimicrobial resistance (AMR) to antibiotics such as co-amoxiclav. AIMS: We aimed to (1) examine the AMR patterns of paediatric urinary E. coli isolates, from both hospital and community sources, over a 10-year period; (2) assess the effectiveness of Children's Health Ireland (CHI) antimicrobial guidance given local susceptibility data; and (3) review the clinical management of an admitted patient sub-set over a 6-year period. METHODS: Pure growth of urinary E. coli from patients aged ≤ 14 from 2012 to 2021 were analysed for AMR. Differences in susceptibility rates were assessed. A retrospective chart review conducted on inpatients aged ≥ 2 months to ≤ 14 years, 2016-2021. RESULTS: E. coli accounted for 70.8% of likely significant positive pure growth cultures (9314 isolates). Susceptibility to co-amoxiclav significantly increased over time, from 66.7% to 80.4% (2016-2021, p < 0.001). Nitrofurantoin and cefalexin had significantly higher susceptibility rates than trimethoprim (< 70% annually). 85.1% of isolates were susceptible to the combination of co-amoxiclav and gentamicin, recommended for those > 2months and systemically unwell. The additional gain in empiric susceptibility provided by gentamicin above that provided by co-amoxiclav alone has fallen from 16.4% to 6.7% (2016-2021). The 222 clinical cases reviewed showed improved antimicrobial guideline compliance over time. CONCLUSIONS: This study provides important regional AMR data. Co-amoxiclav susceptibility increased significantly over time, contrasting with previous studies. This was temporally associated with stewardship measures reducing co-amoxiclav prescribing. Decreasing utility of gentamicin supports recent CHI guideline updates reducing gentamicin use.

Identifying signs and symptoms of urinary tract infection from emergency department clinical notes using large language models.

BACKGROUND: Natural language processing (NLP) tools including recently developed large language models (LLMs) have myriad potential applications in medical care and research, including the efficient labeling and classification of unstructured text such as electronic health record (EHR) notes. This opens the door to large-scale projects that rely on variables that are not typically recorded in a structured form, such as patient signs and symptoms. OBJECTIVES: This study is designed to acquaint the emergency medicine research community with the foundational elements of NLP, highlighting essential terminology, annotation methodologies, and the intricacies involved in training and evaluating NLP models. Symptom characterization is critical to urinary tract infection (UTI) diagnosis, but identification of symptoms from the EHR has historically been challenging, limiting large-scale research, public health surveillance, and EHR-based clinical decision support. We therefore developed and compared two NLP models to identify UTI symptoms from unstructured emergency department (ED) notes. METHODS: The study population consisted of patients aged ≥ 18 who presented to an ED in a northeastern U.S. health system between June 2013 and August 2021 and had a urinalysis performed. We annotated a random subset of 1250 ED clinician notes from these visits for a list of 17 UTI symptoms. We then developed two task-specific LLMs to perform the task of named entity recognition: a convolutional neural network-based model (SpaCy) and a transformer-based model designed to process longer documents (Clinical Longformer). Models were trained on 1000 notes and tested on a holdout set of 250 notes. We compared model performance (precision, recall, F1 measure) at identifying the presence or absence of UTI symptoms at the note level. RESULTS: A total of 8135 entities were identified in 1250 notes; 83.6% of notes included at least one entity. Overall F1 measure for note-level symptom identification weighted by entity frequency was 0.84 for the SpaCy model and 0.88 for the Longformer model. F1 measure for identifying presence or absence of any UTI symptom in a clinical note was 0.96 (232/250 correctly classified) for the SpaCy model and 0.98 (240/250 correctly classified) for the Longformer model. CONCLUSIONS: The study demonstrated the utility of LLMs and transformer-based models in particular for extracting UTI symptoms from unstructured ED clinical notes; models were highly accurate for detecting the presence or absence of any UTI symptom on the note level, with variable performance for individual symptoms.

Appropriate prescription of cytobacteriological urine examinations in older adults.

Cytobacteriological urine examinations (CBEU) are frequently ordered for the older adults, sometimes without straightforward indication and with the risk of prescribing empirical antibiotics. The aim of this study was to evaluate the relevance of the CBEU prescription and empiric antibiotic therapy in our geriatric hospital. Among 129 patients (mean age 84 years, sex ratio 0.69), 229 CBEU were collected with 20.9% of inappropriate indication. Cultures were sterile in 43% (n = 99) of cases and positive in 57% (n = 130) cases. Gram-negative bacilli dominated the isolated bacteria (76.9%) followed by gram-positive cocci (17.6%). In 113 patients, probabilistic antibiotic therapy was prescribed of which 68 treatments were initiated before the CBEU. Ceftriaxone and amoxicillin plus clavulanic acid were the main therapeutic option used representing 70.8% of cases. Antibiotic therapy was re-evaluated after 3 days in 74.3% of patients. Efforts to reduce the number of useless ECBUs by training doctors to follow official guidelines are a priority.

Pharmacokinetic and pharmacodynamic evaluation of nitrofurantoin against Escherichia coli in a murine urinary tract infection model.

The antimicrobial agent nitrofurantoin is becoming increasingly important for treatment of urinary tract infections (UTIs) due to widespread occurrence of multidrug-resistant Escherichia coli. Despite many years of use, little data on nitrofurantoin pharmacokinetics (PK) or -dynamics (PD) exist. The objective of this study was to (i) evaluate the pharmacokinetics of nitrofurantoin in a mouse model and (ii) use that data to design an in vivo dose fractionation study in an experimental model of UTI with E. coli for determination of the most predictive PK/PD index. Nitrofurantoin concentrations in urine were approximately 100-fold larger than concentrations in plasma after oral administration of 5, 10, and 20 mg/kg nitrofurantoin. The area under the curve over the minimum inhibitory concentration (AUC/MIC) was weakly correlated to bacterial reduction in urine (r2 = 0.24), while no such correlation was found for the time that nitrofurantoin stayed above the MIC (T > MIC). Increasing size of single-dose treatment was significantly correlated to eradication of bacteria in the urine, while this was not apparent when the same doses were divided in 2 or 3 doses 8 or 12 h apart. In conclusion, the results indicate that nitrofurantoin activity against E. coli in urine is driven by AUC/MIC.

Small Molecule IITR08367 Potentiates Antibacterial Efficacy of Fosfomycin against Acinetobacter baumannii by Efflux Pump Inhibition.

Fosfomycin is a broad-spectrum single-dose therapy approved for treating lower urinary tract infections. Acinetobacter baumannii, one of the five major UTI-causing pathogens, is intrinsically resistant to fosfomycin. Reduced uptake and active efflux are major reasons for this intrinsic resistance. AbaF, a major facilitator superfamily class of transporter in A. baumannii, is responsible for fosfomycin efflux and biofilm formation. This study describes the identification and validation of a novel small-molecule efflux pump inhibitor that potentiates fosfomycin efficacy against A. baumannii. An AbaF inhibitor screening was performed against Escherichia coli KAM32/pUC18_abaF, using the noninhibitory concentration of 24 putative efflux pump inhibitors. The inhibitory activity of IITR08367 [bis(4-methylbenzyl) disufide] against fosfomycin/H+ antiport was validated using ethidium bromide efflux, quinacrine-based proton-sensitive fluorescence, and membrane depolarization assays. IITR08367 inhibits fosfomycin/H+ antiport activity by perturbing the transmembrane proton gradient. IITR08367 is a nontoxic molecule that potentiates fosfomycin activity against clinical strains of A. baumannii and prevents biofilm formation by inhibiting efflux pump (AbaF). The IITR08367-fosfomycin combination reduced bacterial burden by > 3 log10 in kidney and bladder tissue in the murine UTI model. Overall, fosfomycin, in combination with IITR08367, holds the potential to treat urinary tract infections caused by A. baumannii.

Spinal Deformity Manifested by Urinary Tract Infection: A Case of Acute-on-Chronic Mobility Dysfunction.

A 53-year-old man with diabetes mellitus presented to the emergency department with a fever and impaired mobility. A preliminary diagnosis of urinary tract infection was made based on dysuria and pyuria. History-taking revealed a history of gait disturbance and difficult urination. A thorough physical examination suggested a spinal abnormality. MRI scan revealed a narrow spinal canal due to ossification of the posterior longitudinal ligament and diffuse idiopathic skeletal hyperostosis. Throughout the diagnostic process, we employed both vertical tracing to investigate the causes of urinary tract infection and horizontal tracing to explore comorbidities such as diabetes. Additionally, we introduced appropriate social security and support systems under the name of diagnostic excellence.

Scientific Advances in Understanding the Pathogenesis, Diagnosis, and Prevention of Urinary Tract Infection in the Past 10 Years.

Urinary tract infection (UTI) is a very common disease that is accompanied by various complications in the affected person. UTI triggers diverse inflammatory reactions locally in the infected urinary bladder and kidney, causing tissue destruction and organ failure. Moreover, systemic responses in the entire body carry the risk of urosepsis with far-reaching consequences. Understanding the cell-, organ-, and systemic mechanisms in UTI are crucial for prevention, early intervention, and current therapeutic approaches. This review summarizes the scientific advances over the last 10 years concerning pathogenesis, prevention, rapid diagnosis, and new treatment approaches. We also highlight the impact of the immune system and potential new therapies to reduce progressive and recurrent UTI.

Antibiotic Stewardship Interventions for Urinary Tract Infections in Outpatient Settings: A Narrative Review.

Inappropriate antibiotic choice or duration of therapy for urinary tract infections (UTIs) in outpatients is common and is a major contributor to antibiotic overuse. Most studies on outpatient antibiotic stewardship for UTIs follow a pre-design or post-design with a multifaceted intervention; these trials generally have found improvement in appropriateness of antibiotic use for UTI. Audit and feedback was one of the most commonly employed strategies across these trials but may not be sustainable. Future research on antibiotic stewardship for UTIs in outpatients should measure both effectiveness and implementation success.

Urinary Tract Infection in Male Patients: Challenges in Management.

Urinary tract infections in male patients share many of the management principles as used in the management of female patients, including the need to accurately define the clinical syndrome, choose empirical therapy based on the severity of illness and the potential for antimicrobial resistance, and consider the need for source control in severely ill patients. The microbiology of the causative organisms is more unpredictable compared to female patients, and data to inform treatment decisions from clinical trials specific to male patients are relatively scarce.

Recurrent UTI in Women-Risk Factors and Management.

Urinary tract infections (UTIs) are common in women; more than 50% of women will be diagnosed with a UTI in her lifetime. Many of these women will go on to develop recurrent UTI. Nevertheless, evidence-based prevention of recurrent UTI is under-utilized. Here, the authors provide detailed practical advice on UTI prevention with a thorough review of the evidence. Non-antibiotic prevention measures discussed include increased fluid intake, vaginal estrogen therapy, methenamine, and cranberry. Antibiotic prophyalxis for carefully selected patients is also discussed.

High Incidence of Antibiotic Resistance in the Uropathogenic Bacteria Associated with Different Urological Diseases and Metabolic Complications: A Single Center Cross-Sectional Study.

Urological diseases affect all age groups and are associated with different urinary complications. Presence of pathogenic bacteria complicates the urological diseases such as chronic kidney disease (CKD), kidney stone disease (KSD), emphysematous pyelonephritis (EPN), and urological cancers (UCs) coinciding with urinary metabolic complications. The One Health concept for preventing the spread of antibiotic resistant opportunistic pathogens necessitates detailed investigation on the virulence and the antibiotic sensitivity patterns of the pathogens from the urinary tract infections (UTIs). This cross-sectional study was aimed to profile the pathogenic bacteria associated with different urological diseases that included urine samples from the patients from a tertiary care hospital. The study included 258 patients representing CKD (15.1%), KSD (28.7%), EPN (15.5%), UC (12.0%), and UTI patients without any urological diseases (28.7%) with overall 70.5% patients showing positive urine culture. Furthermore, other than UTI in patients without any urological diseases (100%), higher culture positive cases were seen in KSD (64.9%), followed by CKD (61.5%), EPN (52.5%), and UC (48.4%). Escherichia coli was the most predominant bacteria in UTI (35.1%) and EPN (66.7%). In KSD, Pseudomonas aeruginosa (41.7%), Staphylococcus aureus (18.8%), and Proteus mirabilis (14.6%) were more common. S. aureus (86.7%) was the most isolated bacteria from the UC cases. Overall rate of multidrug resistance (MDR) was 77.8%. All (100%) E. coli, K. pneumoniae, P. mirabilis, and S. aureus strains were MDR. Among the strains, strong biofilm formation was observed in 73.6%, and 66.7% strains were urease positive. Biofilm was positively correlated with MDR and urease activity. The abundance and distribution of bacteria differed among the urological diseases suggesting their association with the urine metabolite profile. Colonization of MDR pathogens in patients with urological diseases is a serious concern requiring steps to control the emergence of drug resistance and their further spread into the ecosystem.

Unitary Tract Infection Treatment: When to Use What Agents including Beta-lactam Combination Agents.

In this study, the authors review antibiotic treatment options for both acute uncomplicated and complicated urinary tract infection (UTI). In addition, they also review regimens used in the setting of drug-resistant pathogens including vancomycin resistant Enterococcus, extended spectrum beta-lactamase (ESBL) producing Enterobacterals, carbapenem-resistant Enterobacterals and carbapenem-resistant Pseudomonas, which are encountered with increasing frequency.

[Case-based presentation of the S2e guideline on the diagnosis and treatment of benign prostatic hyperplasia]. / Fallbasierte Vorstellung der S2e-Leitlinie Diagnostik und Therapie des benignen Prostatasyndroms (BPS).

Benign prostatic hyperplasia (BPH) is the most common disease of the lower urinary tract in men. The prevalence increases continuously with increasing age and a chronic progressive course is to be expected. In order to reduce the morbidity of affected patients and to improve their quality of life, the expert panel Benign Prostatic Hyperplasia (BPH) of the German Society of Urology (DGU) has written a new version of the evidence-based "S2e guideline on the diagnosis and treatment of BPH". Using a current patient case, the contents of the new S2e guideline are illustrated, from diagnosis to the decision-making process for a suitable treatment choice. The case presented here shows the possible complexity and difficulty that can arise in the diagnosis of BPH, the need for further diagnostic steps and the finding of a suitable therapy in order to fulfill the patient's wishes, if possible.

[Nephropathology of infectious disease]. / Nephropathologie infektiöser Erkrankungen.

Infections can affect the kidney via different pathways. Urinary tract infections can directly involve the renal tissue by spreading along pre-existing canalicular structures. Such an ascending infection can manifest as a highly active and purulent or even abscessing interstitial nephritis or as a chronic-fibrosing process in recurrent pyelonephritis. Viral infections can also use the canalicular route as in polyomavirus nephropathy or spread via the blood stream in a hematogenous manner as in the case of cytomegalovirus or hantavirus infections. Likewise, bacterial infections can reach the kidney via the blood in the case of systemic infection. Another large group of nephropathies taking place as a sequel of infections includes infection-related glomerulonephritides (IRGN), which are mediated by a series of immunological mechanisms. These IRGN can be subdivided according to their temporal association with the infectious process, occurring either after the infection has healed (postinfectious) or accompanying the ongoing infectious process (parainfectious). The latter, in particular, is of increasing importance in the daily practice of nephropathologists, especially in older patients. A number of other glomerulonephritis forms, i.e., membranous or membranoproliferative forms, can occur as a consequence of infection. In addition, infections can trigger nephropathies, such as thrombotic microangiopathy. The present article gives an overview of morphologic changes in renal parenchyma that take place as a consequence of infectious processes, with particular focus on IRGN.

Multidrug resistance in pathogenic Escherichia coli isolates from urinary tract infections in dogs, Spain.

Escherichia coli (E. coli) is a pathogen frequently isolated in cases of urinary tract infections (UTIs) in both humans and dogs and evidence exists that dogs are reservoirs for human infections. In addition, E. coli is associated to increasing antimicrobial resistance rates. This study focuses on the analysis of antimicrobial resistance and the presence of selected virulence genes in E. coli isolates from a Spanish dog population suffering from UTI. This collection of isolates showed an extremely high level of phenotypic resistance to 1st-3rd generation cephalosporins, followed by penicillins, fluoroquinolones and amphenicols. Apart from that, 13.46% of them were considered extended-spectrum beta-lactamase producers. An alarmingly high percentage (71.15%) of multidrug resistant isolates were also detected. There was a good correlation between the antimicrobial resistance genes found and the phenotypic resistance expressed. Most of the isolates were classified as extraintestinal pathogenic E. coli, and two others harbored virulence factors related to diarrheagenic pathotypes. A significant relationship between low antibiotic resistance and high virulence factor carriage was found, but the mechanisms behind it are still poorly understood. The detection of high antimicrobial resistance rates to first-choice treatments highlights the need of constant antimicrobial resistance surveillance, as well as continuous revision of therapeutic guidelines for canine UTI to adapt them to changes in antimicrobial resistance patterns.

A Retrospective Study on UTI by Myroides Species: An Emerging Drug Resistant Nosocomial Pathogen.

Aim and background: Myroides (M.) species are ubiquitous in the environment and cause a variety of infections like urinary tract infections (UTI), sepsis, meningitis, cholecystitis, pneumonia, and soft tissue infections, especially among immunocompromised populations. These are usually resistant to multiple antibiotics. This study aimed to demonstrate the clinical profile, underlying comorbidities, and antimicrobial susceptibility of Myroides isolates obtained from nosocomial UTI cases. Materials and methods: A sudden rise in the isolation of Myroides spp. from the repeated urine samples of admitted patients alerted us to conduct this retrospective observational study. Urine cultures that grew M. species were included in this study. Antibiotic susceptibility was performed and the patient's clinical data was analyzed. Results: A total of 14 Myroides spp. isolates were obtained from urine culture. The maximum number of cases (71.4%) were from the Nephrology ward and ICUs. The average (mean) age of patients was 46 years (range 2-80 years). All patients were catheterized. All isolates were multidrug resistant. Minocycline and doxycycline were the only drugs found effective in this study. Conclusions: Myroides species are emerging rare pathogens that can cause UTI in immunocompromised and catheterized patients. Minocycline may be used for treating such infections. How to cite this article: Sahu C, Chaudhary R, Bhartiya C, Patel SS, Bhatnagar N. A Retrospective Study on UTI by Myroides Species: An Emerging Drug Resistant Nosocomial Pathogen. Indian J Crit Care Med 2024;28(4):399-403.

Reducing Recurrent Urinary Tract Infections in Women with MV140 Impacts Personal Burden of Disease: Secondary Analyses of a Randomized Placebo-controlled Efficacy Study.

Background: Recurrent urinary tract infection (rUTI) remains a major health burden for women. A randomized, double-blind, placebo-controlled trial (RCT; NCT02543827) reported that female patients with rUTI receiving a sublingual vaccine, MV140, had a reduction in rUTI and increase in UTI-free rate compared with placebo. Objective: To determine the impact of MV140 on the personal burden of disease in women with rUTI using secondary endpoint data from the pivotal RCT evaluating MV140. Design setting and participants: In the primary RCT, female patients with rUTI enrolled in Spain and UK (from October 2015 to April 2019) were randomized to placebo (6 mo) or MV140 (3 or 6 mo), and followed for 12 mo. Individuals analyzed in this secondary analysis included those in the placebo and 3-mo (recommended dose) groups. Intervention: A polybacterial sublingual vaccine, MV140 (four inactivated whole-cell bacteria-Escherichia coli, Klebsiella pneumoniae, Proteus vulgaris, and Enterococcus faecalis), or placebo. Outcome measurements and statistical analysis: Symptom severity scoring, antibiotic use, safety, and multiple aspects of quality of life (QoL; Short-Form Questionnaire [SF-36]) were assessed. Results and limitations: Compared with the placebo group (n = 76), the 3-mo vaccinated group (n = 74) experienced fewer overall UTI symptoms (mean symptom score 102.2 ± 222.9 vs 194.2 ± 178.8; p = 0.0002), fewer days on antibiotics (12.4 ± 17.7 vs 28.7 ± 25.2; p = 0.0001), and improved total, general, and physical SF-36 QoL improvement (differences in means for total SF-36 score 15.7; 95% confidence interval [CI] 8.80, 22.64; p < 0.0001), with only social function QoL showing no impact (4.07; 95% CI -4.93, 13.08; p = 0.3744). Conclusions: Three months of MV140 is associated with a reduction of the personal burden of UTI by reducing overall UTI symptoms and antibiotic use, improving QoL in women with rUTI. Patient summary: Three months of MV140 vaccine, which has previously been shown to reduce the risk of urinary tract infection safely, is associated with a reduction in the personal burden of disease.

The Diagnosis and Treatment of Adult Urinary Tract Infections in the Emergency Department.

Emergency medicine has been called the art of "making complicated clinical decisions with limited information." This description is particularly relevant in the case of diagnosis and treatment of urinary tract infections (UTIs). Although common, UTIs are often challenging to diagnose given the presence of non-specific signs and symptoms and over-reliance on laboratory findings. This review provides an interdisciplinary interpretation of the primary literature and practice guidelines, with a focus on diagnostic and antimicrobial stewardship in the emergency department.

Prediction of Postoperative Urinary Tract Infection Following Benign Gynecologic Surgery.

INTRODUCTION AND HYPOTHESIS: The objective was to develop a prediction model for urinary tract infection (UTI) after pelvic surgery. METHODS: We utilized data from three tertiary care centers of women undergoing pelvic surgery. The primary outcome was a UTI within 8 weeks of surgery. Additional variables collected included procedural data, severity of prolapse, use of mesh, anti-incontinence surgery, EBL, diabetes, steroid use, estrogen use, postoperative catheter use, PVR, history of recurrent UTI, operative time, comorbidities, and postoperative morbidity including venous thromboembolism, surgical site infection. Two datasets were used for internal validation, whereas a third dataset was used for external validation. Algorithms that tested included the following: multivariable logistic regression, decision trees (DTs), naive Bayes (NB), random forest (RF), gradient boosting (GB), and multilayer perceptron (MP). RESULTS: For the training dataset, containing both University of British Columbia and Mayo Clinic Rochester data, there were 1,657 patients, with 172 (10.4%) UTIs; whereas for the University of Calgary external validation data, there were a total of 392 patients with a UTI rate of 16.1% (n = 63). All models performed well; however, the GB, DT, and RF models all had an area under the curve (AUC) > 0.97. With external validation the model retained high discriminatory ability, DT: AUC = 0.88, RF: AUC = 0.88, and GB: AUC = 0.90. CONCLUSIONS: A model with high discriminatory ability can predict UTI within 8 weeks of pelvic surgery. Future studies should focus on prospective validation and application of randomized trial models to test the utility of this model in the prevention of postoperative UTI.