Cystitis cystica and recurrent urinary tract infections in children

The pathogenesis of recurrent urinary tract infections (UTIs) in preschool children with anatomically correct urinary tract (UT) is rather obscure. In girls, the bladder wall changes of cystitis cystica (CC) may be per se responsible for UTIs recurrence. During the 20-year period, 127 preschool children (125 girls; median age: 6.1 years) with CC, in whom UT anomalies were excluded, were diagnosed. The mean duration of UTIs symptoms prior to diagnosis was 3.31 +/- 2.51 years. Cystoscopical findings were labelled as mild, moderate and severe in 22.8%, 39.4% and 37.8% of patients, respectively. Following the confirmation of CC, long-term chemoprophylaxis with sulfamethoxazole-trimethoprim/nitrofurantoin was administered. A one year UTI-free period after chemoprophylaxis discontinuation was defined as therapeutic success. With 2.5 years median duration of regular chemoprophylaxis this goal was achieved in 58 children mainly with mild/ moderate CC. Thirty children from "improved/unchanged" group taking regular prophylaxis had significant reduction of UTIs ("improved"). Only 12 children belonging to the same group taking regular prophylaxis and all children with irregular prophylaxis had approximately the same number of UTIs as before treatment ("unchanged"). The "improved/unchanged" outcomes were predominantly found in children with severe form of CC. Although urodynamic disturbances detected in more than 50% of patients in whom urodynamics was performed were not found influential on the disease outcome, they could be responsible for its development. The results of our study suggest that regular and long-lasting chemoprophylaxis remains a basis for successful treatment for majority of patients with CC, even those with severe forms. If not treated properly with chemoprophylactic agents and without fair compliance in taking drugs, the disease is prone to recurrent UTIs.     

Can a concentrated cranberry extract prevent recurrent urinary tract infections in women? A pilot study

BACKGROUND: Urinary tract infections (UTIs) are extremely prevalent and despite treatment with antibiotics, reoccurrences are common causing frustration in the patient and the potential for developing antibiotic resistance. The use of cranberry products to prevent UTIs has recently become popular and more clinical studies are needed to explore this use. OBJECTIVE: This open label pilot study examined the ability of a concentrated cranberry preparation to prevent UTIs in women with a history of recurrent infections. SUBJECTS: Women between the ages of 25 and 70 years old were included with a history of a minimum of 6 UTIs in the proceeding year. INTERVENTION: The women took one capsule twice daily for 12 weeks containing 200 mg of a concentrated cranberry extract standardized to 30% phenolics. DESIGN: A questionnaire was used initially to determine the patient's medical history and they were asked at monthly intervals if any of the information had changed. All of the women in the study had urinalysis within 24h before starting on the study preparation and once a month after that for 4 months. Subjects were followed-up approximately 2 years later. RESULTS: All 12 subjects participated in the 12-week study and were available for follow up 2 years later. During the study none of the women had a UTI. No adverse events were reported. Two years later, eight of the women who continue to take cranberry, continue to be free from UTIs. CONCLUSION: A cranberry preparation with a high phenolic content may completely prevent UTIs in women who are subject to recurrent infections.     

Psychological aspects of lower urinary tract infections in women.

OBJECTIVE--To determine whether women with the urethral syndrome can be distinguished from those with urinary tract infection by case notes, clinical symptoms, or psychiatric state. DESIGN--Longitudinal survey of consecutive women presenting with dysuria and frequency. SETTING--General practice and community. SUBJECTS--58 patients with the urethral syndrome and 44 patients with a urinary tract infection, mean age 39.9 years. MAIN OUTCOME MEASURES--Results of analysis of serial midstream urine specimens, patients'' self rated physical symptoms and responses to 60 item general health questionnaire at presentation and after resolution of symptoms, and results of psychiatric assessment with the clinical psychiatric interview. RESULTS--4 of 42 patients with a urinary tract infection had recently changed sexual partner compared with none of 58 with the urethral syndrome. Dysuria and nocturia were more common in patients with urinary tract infections than those with the urethral syndrome (mean (SD) score for dysuria 5.37 (2.39) v 4.57 (2.13), p less than 0.05; nocturia in 39/44 (88%) patients v 40/58 (69%), chi 2 = 5.5, p less than 0.02). Both groups showed transient high levels of distress which resolved with the physical symptoms, but no psychiatric difference distinguished them. CONCLUSION--The urethral syndrome is not associated with increased psychiatric morbidity.     

Intravaginal instillation of lactobacilli for prevention of recurrent urinary tract infections

Urinary tract infections remain a common problem, particularly in the female population. New methods are required to manage recurrent cystitis, and extensive research to date has suggested that restoration of the lactobacilli flora of the urogenital tract may prevent these infections. In this study, five females suffering from recurrent urinary tract infections were treated twice weekly with intravaginal and perineal implantation of Lactobacillus casei GR-1. These organisms colonized the epithelium and prevented the emergence of coliform bacteria in most instances, but did not appear to affect enterococcal colonization. In vitro studies showed that L. casei GR-1 inhibited the growth of the coliforms but did not inhibit enterococci. Each of the five patients had infection-free periods ranging from 4 weeks to 6 months. The treatment was well tolerated, had no side effects, led to an improved well-being, and was preferred to antibiotic treatment by all of the patients. These human studies, albeit of a limited nature, are the first to examine the potential for lactobacillus therapy in the prevention of urinary tract infections. The results show that lactobacilli therapy, using carefully selected organisms to treat patients who are closely followed, may be effective in the prevention of recurrent urinary tract infections.     

Pheochromocytoma presenting as recurrent urinary tract infections : a case report

Introduction

Idiopathic purpura fulminans is a cutaneous thrombotic disorder usually caused by autoimmune-mediated protein C or S deficiency. This disorder typically presents with purpura and petechiae that eventually slowly or rapidly coalesce into extensive, necrotic eschars on the extremities. We present the first known case of idiopathic purpura fulminans consistent with prior clinical presentations in the setting of a prothrombotic genetic mutation, but without hallmark biochemical evidence of protein C or protein S deficiency. Another novel feature of our patient's presentation is that discontinuation of anti-coagulation has invariably led to recurrence and formation of new lesions, which is unexpected in idiopathic purpura fulminans because clearance of autoimmune factors should be followed by restoration of anti-coagulant function. Although this disease is rare, infants with suspected idiopathic purpura fulminans should be rapidly diagnosed and immediately anti-coagulated to prevent adverse catastrophic outcomes such as amputation and significant developmental delay.

Case presentation

A six-month-old Caucasian boy was brought to our pediatric hospital service with a low-grade fever and subacute, symmetric, serpiginous, stellate, necrotic eschars on his forearms, legs and feet that eventually spread non-contiguously to his toes, thighs and buttocks. In contrast to his impressive clinical presentation, his serologic evaluation was normal, and he was not responsive to corticosteroids and antibiotics. Full-thickness skin biopsies revealed dermal vessel thrombosis, leading to a diagnosis of idiopathic purpura fulminans and successful treatment with low-molecular-weight heparin, which was transitioned to warfarin. Long-term management has included chronic anti-coagulation because of recurrence of lesions with discontinuation of treatment.

Conclusion

In infants with necrotic eschars, it is important to first consider infectious, inflammatory and hematologic etiologies. In the absence of etiology for protracted idiopathic purpura fulminans, management should include tissue biopsy, in which thrombotic findings warrant a trial of empiric anti-coagulation. Some infants, including our patient, may need long-term anti-coagulation, especially when the underlying etiology of coagulation remains unidentified and symptoms recur when treatment is halted. Given that our patient still requires anti-coagulation, he may have a yet to be identified autoimmune-mediated mechanism for his truly idiopathic case of protracted purpura fulminans.     

Catheter-associated urinary tract infections in intensive care units

The purpose of this review is to analyze literature concerning the diagnosis, prevention, and management of catheter-associated urinary tract infection (CAUTI) occurring in patients hospitalized in the intensive care unit (ICU). Analysis was performed from personal and "Pubmed" data, crossing the following keywords: "urinary tract infection", "catheter', and "intensive care unit". Few clinical trials including ICU patients were found despite the abundance of expert opinions. There is no consensus on the use of urinary reagent tests for diagnosis. The prevention of CAUTI in ICU patients does not require expensive devices. Neither complex closed drainage systems nor silver-coated urinary catheters have demonstrated efficacy in comparative randomized clinical trials. Bladder irrigation should not be used, except when an obstruction of the catheter is highly likely. The administration of prophylactic antimicrobial therapy, although effective in reducing the incidence of urinary bacteria, cannot be recommended in ICU patients. The management of CAUTI in ICU patients has not been evaluated in clinical trials. The level of evidence provided in this field is weak, and underlines the need for randomized studies to improve management of patients.