Hyperammonemia in Urinary Tract Infections

Objectives

The present study investigated the incidence of hyperammonemia in urinary tract infections and explored the utility of urinary obstruction relief and antimicrobial administration to improve hyperammonemia.

Methods

This was an observational study. Subjects were patients who were diagnosed with urinary tract infection and hospitalized between June 2008 and June 2009. We measured plasma ammonia levels on admission in patients who were clinically diagnosed with urinary tract infection and hospitalized. We assessed each patient''s level of consciousness on admission using the Glasgow Coma Scale (GCS) and performed urine and blood cultures. We also assessed hearing prior to hospitalization using the Eastern Cooperative Oncology Group performance status (ECOG-PS). In cases with high ammonia levels on admission, plasma ammonia and GCS were measured 24 hours and 5–7 days later.

Results

Sixty-seven candidates were enrolled; of these, 60 cases (89.6%) with bacterial cell counts ≥10⁴ CFU/mL were studied. Five cases (8.3%) presented with high plasma ammonia levels. Cases with hyperammonemia were significantly more likely to present with low GCS scores and urinary retention rate. All five cases received antimicrobial therapy with an indwelling bladder catheter to relieve urinary retention. The case 5 patient died shortly after admission due to complicated aspiration pneumonia; in the remaining cases, plasma ammonia levels were rapidly normalized and the level of consciousness improved.

Conclusions

The occurrence of hyperammonemia in urinary tract infections is not rare. The cause of hyperammonemia is urinary retention obstruction. Therefore, along with antimicrobial administration, relief of obstruction is important for the treatment of hyperammonemia caused by this mechanism.     

Yeast Infections of the Lower Urinary Tract: Recommendations for Diagnosis and Treatment

Yeast infections of the lower urinary tract are common, with the vast majority due to Candida species. Though not life-threatening, candiduria may be a marker for overall severity of illness in hospitalized patients, as it appears to predict increased mortality, particularly in critically ill patients. Diagnosis is relatively simple through culture, but exact definitions of clinical disease are elusive. Management of asymptomatic patients is generally observation with reduction of predisposing factors, whereas symptomatic patients should be treated. Therapeutic options for these infections are limited and not well studied compared with therapies for systemic candidiasis. Further studies are needed to optimize management of these patients.     

Secretory IgA in Urinary Tract Infections

Secretory IgA, measured by radial immunodiffusion, was compared in the urine of children with chronic and recurrent non-obstructive urinary tract infections with that in normal children. IgA, IgG, and IgM were also measured. Absent and low levels of IgA(s) were found in both groups; however, the mean levels of IgA(s) were significantly higher in the infected group compared with normals—3·3 to 0·78 mg./24 hours, respectively. Secretory IgA was found to be locally produced in the bladder. It is suggested that IgA(s) levels reflect an antibody response to infection.     

Determinants of Antimicrobial Resistance in Escherichia coli Strains Isolated from Faeces and Urine of Women with Recurrent Urinary Tract Infections

For women with recurrent urinary tract infections (rUTI), the contribution of antibiotic use versus patient-related factors in determining the presence of antimicrobial resistance in faecal and urinary Escherichia coli, obtained from the same patient population, has not been assessed yet. Within the context of the ‘Non-antibiotic prophylaxis for recurrent urinary tract infections’ (NAPRUTI) study, the present study assessed determinants of antimicrobial resistance in E. coli isolated from urinary and faecal samples of women with rUTIs collected at baseline. Potential determinants of resistance were retrieved from self-administered questionnaires. From 434 asymptomatic women, 433 urinary and 424 faecal samples were obtained. E. coli was isolated from 146 (34%) urinary samples and from 336 (79%) faecal samples, and subsequently tested for antimicrobial susceptibility. Multivariable analysis showed trimethoprim/sulfamethoxazole (SXT) use three months prior to inclusion to be associated with urine E. coli resistance to amoxicillin (OR 3.6, 95% confidence interval: 1.3–9.9), amoxicillin-clavulanic acid (OR 4.4, 1.5–13.3), trimethoprim (OR 3.9, 1.4–10.5) and SXT (OR 3.2, 1.2–8.5), and with faecal E. coli resistance to trimethoprim (OR 2.0, 1.0–3.7). The number of UTIs in the preceding year was correlated with urine E. coli resistance to amoxicillin-clavulanic acid (OR 1.11, 1.01–1.22), trimethoprim (OR 1.13, 1.03–1.23) and SXT (OR 1.10, 1.01–1.19). Age was predictive for faecal E. coli resistance to amoxicillin (OR 1.02, 1.00–1.03), norfloxacin and ciprofloxacin (both OR 1.03, 1.01–1.06). In conclusion, in women with rUTI different determinants were found for urinary and faecal E. coli resistance. Previous antibiotic use and UTI history were associated with urine E. coli resistance and age was a predictor of faecal E. coli resistance. These associations could best be explained by cumulative antibiotic use.     

Transferable Drug Resistance Among Enterobacteriaceae Isolated from Human Urinary Tract Infections

Fifteen sulfonamide-resistant cultures isolated from urinary tract infections in eastern Nebraska were screened for transferable drug resistance by three methods. Seven of the 15 resistant cultures could transfer resistance of varying levels to two or more chemotherapeutic agents. Transfer of drug resistance occurred without accompanying transfer of chromosomal traits and required cell to cell contact. In mixed culture, the number of drug-resistant recipients increased exponentially, reaching a plateau 2 hr after mixing. Spontaneous or artificial elimination of resistance was found to be a rare event. In addition, several drug-sensitive isolates from urinary tract infections were shown to be competent recipients of drug resistance determinants. From these data, it appears that the transferable drug resistance observed was mediated by R factors.     

Microbiology of Urinary Tract Infections in Gaborone,Botswana

Objective

The microbiology and epidemiology of UTI pathogens are largely unknown in Botswana, a high prevalence HIV setting. Using laboratory data from the largest referral hospital and a private hospital, we describe the major pathogens causing UTI and their antimicrobial resistance patterns.

Methods

This retrospective study examined antimicrobial susceptibility data for urine samples collected at Princess Marina Hospital (PMH), Bokamoso Private Hospital (BPH), or one of their affiliated outpatient clinics. A urine sample was included in our dataset if it demonstrated pure growth of a single organism and accompanying antimicrobial susceptibility and subject demographic data were available.

Results

A total of 744 samples were included. Greater than 10% resistance was observed for amoxicillin, co-trimoxazole, amoxicillin-clavulanate, and ciprofloxacin. Resistance of E. coli isolates to ampicillin and co-trimoxazole was greater than 60% in all settings. HIV status did not significantly impact the microbiology of UTIs, but did impact antimicrobial resistance to co-trimoxazole.

Conclusions

Data suggests that antimicrobial resistance has already emerged to most oral antibiotics, making empiric management of outpatient UTIs challenging. Ampicillin, co-trimoxazole, and ciprofloxacin should not be used as empiric treatment for UTI in this context. Nitrofurantoin could be used for simple cystitis; aminoglycosides for uncomplicated UTI in inpatients.     

Prevention of Urinary Tract Infections After Vaginal Surgery

The technique of care of the bladder and indwelling catheter during the postoperative period was altered to determine whether the incidence of urinary tract infections following vaginal surgery could be reduced. Sixty-nine patients undergoing various types of vaginal reparative surgery were studied. Irrigation of the bladder was carried out with a closed system, four times daily, using chlorhexidine diacetate 1:20,000. Only 12 of the 69 patients showed urinary infection after removal of the catheter, a marked reduction in the usual incidence. It is suggested, therefore, that this technique is helpful in preventing urinary infection after vaginal surgery. It was noted, however, that a further 12 patients who were free of infection at the time of removal of the catheter subsequently developed infection as a result of catherization for residual urine. It is recommended that routine catheterization for residual urine be abandoned.