Accurate topographical diagnosis of urinary tract infection in male patients with (111)indium-labelled leukocyte scintigraphy

Diagnosis and management of male urinary tract infections: a need for new guidelines. Study from a French general practice electronic database

BACKGROUND

The definition and the treatment of male urinary tract infections (UTIs) are imprecise. This study aims to determine the frequency of male UTIs in consultations of general practice, the diagnostic approach and the prescribed treatments.

METHODS

We extracted the consultations of male patients, aged 18 years or more, during the period 2012-17 with the International Classification of Primary Care, version 2 codes for UTIs or associated symptoms from PRIMEGE/MEDISEPT databases of primary care. For eligible consultations in which all symptoms or codes were consistent with male UTIs, we identified patient history, prescribed treatments, antibiotic duration, clinical conditions, additional examinations and bacteriological results of urine culture.

RESULTS

Our study included 610 consultations with 396 male patients (mean age 62.5 years). Male UTIs accounted for 0.097% of visits and 1.44 visits per physician per year. The UTIs most commonly identified were: undifferentiated (52%), prostatitis (36%), cystitis (8.5%) and pyelonephritis (3.5%). Fever was recorded in 14% of consultations. Urine dipstick test was done in 1.8% of consultations. Urine culture was positive for Escherichia coli in 50.4% of bacteriological tests. Fluoroquinolones were the most prescribed antibiotics (64.9%), followed by beta-lactams (17.4%), trimethoprim-sulfamethoxazole (11.9%) and nitrofurantoin (2.6%).

CONCLUSIONS

Male UTIs are rare in general practice and have different presentations. The definition of male UTIs needs to be specified by prospective studies. Diagnostic evidence of male cystitis may reduce the duration of antibiotic therapy and spare critical antibiotics.

111In-Labeled White Blood Cell Uptake in the Urinary Bladder in Occult Urinary Tract Infection

ABSTRACT

A 55-year-old woman with multiple medical problems, including anuric, dialysis-dependent, end-stage renal disease, presented with persistent fever of unknown origin. Despite extensive workup with cross-sectional imaging and panculture, the etiology was not found. Eventually, an 111In-labeled WBC scan was performed to evaluate for occult infection, which revealed intense heterogeneous uptake in the urinary bladder. Subsequent bladder catheterization showed pus and blood, which grew Klebsiella pneumoniae. The fevers resolved with adjustment of the therapy. Although urinary analysis and culture are standard practice in the workup of fever of unknown origin, anuria may obscure this common source of infection.

Frequency and clinical significance of prostatic involvement in men with febrile urinary tract infection: a prospective observational study

Background: Frequent asymptomatic involvement of the prostate has been demonstrated in men with febrile urinary tract infection (fUTI). In view of this, men with fUTI are often given a longer duration of antibiotic treatment; however, evidence to support this is limited. Methods: We prospectively studied adult men with fUTI admitted under the Department of Medicine in a tertiary care hospital in southern India.  fUTI was defined as fever of ≥38°C with at least one symptom/sign of UTI and pyuria, requiring hospitalization. We estimated serum total prostate-specific antigen (PSA) levels at enrollment, one month and three months after treatment completion. We assessed prostatic volume by transrectal ultrasonography (TRUS) and estimated the serum high sensitivity C-reactive protein (hs-CRP) levels at baseline and after three months. Results: We enrolled 64 men (median [IQR] age 53 [45-60] years); 50 patients completed follow-up. At baseline, 24 (38%) of 64 patients had elevated serum PSA values compared to age-specific upper limit. The median (IQR) serum PSA level was 2.15 (1.18-3.02) ng/mL and median (IQR) serum hs-CRP level was 2.23 (1.85-2.74) mg/dL (N=64). At three months, serum PSA levels decreased by ≥25% in 47 (94%) of 50 patients. The median (IQR) of prostatic volume was 25.4 (18.9-34) mL at baseline (N=64), and ≥10% decrease in prostatic volume was observed in 24 (48%) of 50 patients at three months. The change in the serum PSA levels did not correlate with clinical findings like prostatic tenderness or with prostatic volume changes. Further, serum PSA levels did not correlate with hs-CRP levels. On follow-up, seven patients had lower urinary tract symptoms; only one of them had recurrent fUTI.   Conclusions: Asymptomatic prostatic involvement, although common in men with fUTI, does not seem to influence the treatment outcomes.

High prevalence of upper urinary tract involvement detected by 111indium-oxine leukocyte scintigraphy in patients with candiduria

The purpose of this investigation was to assess the prevalence of upper urinary tract involvement in patients with candiduria by means of (111)indium-oxine-labeled leukocyte scintigraphy. An observational cohort study of patients with confirmed candiduria was conducted in an acute-care teaching hospital in Spain from March 2006 through February 2009. An (111)In-labeled leukocyte scan was performed in order to assess the upper urinary tract involvement. A series of non-matched patients without candiduria nor bacteriuria undergoing scintigraphy to exclude infections in other sites than the urinary tract was also studied. Demographics, baseline illness, and clinical data were recorded. Candiduria was detected in 428 patients, and scintigraphy was performed in 35 of these patients. Twenty-nine patients without candiduria nor bacteriuria were also studied. Positive renal scintigraphy was documented in 24 (68%) patients with confirmed candiduria and in 3 (10%) patients without candiduria (p < 0.005). Renal uptake was not associated with a higher mortality nor with re-admissions. Subclinical pyelonephritis could be more frequent in patients with candiduria than it has been previously considered.

Prevalence and risk factors for quinolone resistance among Escherichia coli strains isolated from males with community febrile urinary tract infection

The purpose of this study was to evaluate the prevalence and clinical risk factors for quinolone resistance (QR) in E. coli strains from males with febrile urinary tract infection (FUTI). An ambispective cross-sectional study was performed in which we evaluated 153 males with a community FUTI caused by E. coli. Among the 153 FUTI episodes, 101 (66%) were due to quinolone susceptible E. coli strains while 52 (34%) were caused by QR E. coli strains. In the univariate analysis QR was associated with older age, higher Charlson scores, dementia, past UTI, urinary tract abnormalities, previous antibiotic use, particularly with fluoroquinolones (FQ), a healthcare-associated (HA)-UTI (HA-UTI) and to four of the components included in the definition of HA-UTI: hospital admission, nursing home residence, indwelling urethral catheter and invasive urinary instrumentation. In the multivariate analysis, HA-UTI (OR 3.82, 95% CI 1.3-11.24; P 0.015) and use of antimicrobials in the previous month (OR 5.82, 95% CI 2.3-14.88; P < 0.001) mainly with FQ (OR 13.97, 95% CI 2.73-71.53; P 0.002) were associated with QR. To have a HA-UTI and a previous use of FQ in the preceding month were strong risk factors for QR E. coli, and thus empirical antimicrobial treatment with quinolones should be avoided in these patients.

Acute bacterial prostatitis: heterogeneity in diagnostic criteria and management. Retrospective multicentric analysis of 371 patients diagnosed with acute prostatitis

BACKGROUND

There is currently a lack of consensus for the diagnosis, investigations and treatments of acute bacterial prostatitis (AP).

METHODS

The symptoms, investigations and treatments of 371 inpatients diagnosed with AP were analyzed through a retrospective study conducted in four departments - Urology (U), Infectious Diseases (ID), Internal Medicine (IM), Geriatrics (G) - of two French university hospitals.

RESULTS

The cause of admission, symptoms, investigations and treatments depended markedly on the department of admission but not on the hospital. In U, patients commonly presented with a bladder outlet obstruction, they had a large imaging and functional check-up, and received alpha-blockers and anti-inflammatory drugs. In ID, patients were febrile and received longer and more appropriate antibiotic treatments. In G, patients presented with cognitive disorders and commonly had post-void urine volume measurements. In IM, patients presented with a wide range of symptoms, and had very diverse investigations and antibiotic regimen.Overall, a 3:1 ratio of community-acquired AP (CA-AP) to nosocomial AP (N-AP) was observed. Urine culture isolated mainly E. coli (58% of AP, 68% of CA-AP), with venereal agents constituting less than 1%. The probabilistic antibiotic treatments were similar for N-AP and CA-AP (58% bi-therapy; 63% fluoroquinolone-based regimen). For N-AP, these treatments were more likely to be inadequate (42% vs. 8%, p < 0.001) and had a higher rate of bacteriological failure (48% vs. 19%, p < 0.001). Clinical failure at follow-up was more common than bacteriological failure (75% versus 24%, p < 0.001). Patients older than 49 had more underlying urinary tract disorders and a higher rate of clinical failure (30% versus 10%, p < 0.0001).

CONCLUSION

This study highlights the difficulties encountered on a daily basis by the physicians regarding the diagnosis and management of acute prostatitis.