Clinical and epidemiological features and prognosis of complicated pyelonephritis: a prospective observational single hospital-based study

A Systematic Literature Review of the Epidemiology of Complicated Urinary Tract Infection

INTRODUCTION

Urinary tract infections (UTIs) are common bacterial infections and present with heterogeneous clinical phenotypes. Whereas many uncomplicated UTIs resolve spontaneously or with antibiotic treatment, a complicated UTI (cUTI) presents with greater morbidity and a higher risk of treatment failures. The goal of this study was to estimate the real-world epidemiology of cUTI, including acute pyelonephritis (AP) and catheter-associated UTIs (CAUTIs), and its associated mortality internationally.

METHODS

A systematic literature search was conducted using PubMed, Embase, Cochrane, and EconLit databases for relevant articles published between July 2013 and July 2023 covering Europe and the following countries: France, Italy, Germany, Spain, the UK, China, Japan, and the US (US). Search terms relating to cUTI, AP, CAUTI, outcomes of interest (epidemiology), and real-world research designs were used. There were no language limitations (protocol registry: PROSPERO-CRD42023454794).

RESULTS

Database searches yielded 1014 unique records, of which 91 met the prespecified inclusion criteria; bibliography and conference abstract searches yielded 27 additional records for a total of 118 records for inclusion. Disease presentation and reported outcomes varied widely across studies, and most studies reporting incidence and prevalence of cUTI were from the US (21 of 29). No studies reporting incidence or prevalence rates of cUTI in China, Germany, or the UK were identified. Overall, high antibiotic resistance rates were reported in both inpatient and outpatient settings. The inpatient cohort mortality rates were highly variable (0-50%) depending on the patient population.

CONCLUSIONS

While disease presentation and reported outcomes varied widely across studies, cUTIs represent a considerable burden in terms of incidence, prevalence, drug resistance, and mortality, yet vast knowledge gaps remain in the literature. There is a crucial need to address these gaps to effectively evaluate new treatments and improve future analyses of cUTI burden and outcomes.

Radiological Explorations of Patients with Upper or Febrile Urinary Tract Infection

Recent European Association of Urology (EAU) guidelines and a clinical prediction rule developed by Van Nieuwkoop et al. suggest simple criteria for performing radiological imaging for patients with a febrile urinary tract infection (UTI). We analysed the records of patients with a UTI from four hospitals in Switzerland. Of 107 UTI patients, 58% underwent imaging and 69% (95%CI: 59-77%) and 64% (95%CI: 54-73%) of them were adequately managed according to Van Nieuwkoop's clinical rule and EAU guidelines, respectively. However, only 47% (95%CI: 33-61%) and 57% (95%CI: 44-69%) of the imaging performed would have been recommended according to their respective rules. Clinically significant imaging findings were associated with a history of urolithiasis (OR = 11.8; 95%CI: 3.0-46.5), gross haematuria (OR = 5.9; 95%CI: 1.6-22.1) and known urogenital anomalies (OR = 5.7; 95%CI: 1.8-18.2). Moreover, six of 16 (38%) patients with a clinically relevant abnormality displayed none of the criteria requiring imaging according to Van Nieuwkoop's rule or EAU guidelines. Thus, adherence to imaging guidelines was suboptimal, especially when imaging was not recommended. However, additional factors associated with clinically significant findings suggest the need for a new, efficient clinical prediction rule.

Early versus delayed ureterolithotripsy following obstructive acute pyelonephritis treatment

BACKGROUND AND OBJECTIVES

There is no recommendation on the timing of ureterolithotripsy after the treatment of obstructive acute pyelonephritis (APN). The effect of early and delayed ureterolithotripsy on postoperative urinary tract infection (UTI) and other complications was investigated.

METHODS

Patients who underwent ureterolithotripsy after obstructive APN treatment between February 2017 and August 2021 were divided into two groups, those operated during hospitalization and those operated within 3 months after discharge. Two groups were compared in terms of stone-free status, postoperative complications, postoperative UTI, and urosepsis rates.

RESULTS

Of the 91 patients included in the study, 68 were in the early ureterolithotripsy group, while 23 patients were in the delayed ureterolithotripsy group. The postoperative UTI rate was significantly higher in patients who underwent early ureterolithotripsy (29.4% vs 8.7%, p = 0.045). Patients with postoperative UTI had a higher moderate/severe perinephric fat stranding (PFS) on non-contrast CT at hospital admission (52.2% vs 29.4%, p = 0.048). Among the laboratory parameters, white blood cells were significantly higher in the group with postoperative UTI (21604.5 vs 14728.9, p = 0.042). In the multivariate analysis, early ureterolithotripsy and moderate/severe PFS were independent predictors for postoperative UTI. In the created model, the probability of postoperative UTI after ureterolitripsy after obstructive APN treatment was 3.5% in patients without risk factors, while this rate was 51.9% in patients with both risk factors.

CONCLUSION

There is no consensus on the timing of stone removal after treatment of obstructive APN. Early ureterolithoripsy and moderate/severe perinephric fat stranding on non-contrast CT are risk factors for postoperative UTI.

Temporal changes in incidence of hospital-diagnosed acute pyelonephritis: A 19-year population-based Danish cohort study

Objectives

To examine temporal changes in the incidence of hospital-diagnosed acute pyelonephritis (APN) and characterize associated demographics.

Methods

Cohort study including Danish patients with hospital-diagnosed APN during 2000-2018, identified by International Classification of Diseases, 10th Revision codes. Annual sex- and age-standardized incidence rates per 10,000 person years with 95% confidence intervals (CIs) were stratified by sex, age group, diagnosis code, and region of residence. Incidence rates for selected urinary tract infections and sepsis diagnoses were also computed.

Results

We included 66,937 hospital-diagnosed APN episodes in 57,162 patients. From 2000 to 2018, the incidence increased from 6.8 (95% CI: 6.8-6.8) to 15.4 (95% CI: 15.4-15.4) in women and from 2.7 (95% CI: 2.7-2.7) to 4.5 (95% CI: 4.5-4.5) in men. Among infants, the rate rose from 7.4 (95% CI: 7.4-7.4) to 64.8 (95% CI: 64.7-64.9) in girls and from 17.1 (95% CI: 17.1-17.2) to 52.5 (95% CI: 52.4-52.6) in boys. Concomitant declines were observed in incidences of hospital-diagnosed unspecified urinary tract infections and sepsis.

Conclusion

The APN incidence roughly doubled during 2000-2018. The increase was largely driven by a prominently increasing incidence among young children which was not explained by the enlarging prevalence of congenital anomalies of the kidney and urinary tract.

Risk Factors for Bacteremia and Its Clinical Impact on Complicated Community-Acquired Urinary Tract Infection

Bacteremia has been associated with severity in some infections; however, its impact on the prognosis of urinary tract infections (UTIs) is still disputed. Our goal is to determine the risk factors for bacteremia and its clinical impact on hospitalized patients with complicated community-acquired urinary tract infections. We conducted a prospective observational study of patients admitted to the hospital with complicated community-acquired UTIs. Clinical variables and outcomes of patients with and without bacteremia were compared, and multivariate analysis was performed to identify risk factors for bacteremia and mortality. Of 279 patients with complicated community-acquired UTIs, 37.6% had positive blood cultures. Risk factors for bacteremia by multivariate analysis were temperature ≥ 38 °C (p = 0.006, OR 1.3 (95% CI 1.1-1.7)) and procalcitonin ≥ 0.5 ng/mL (p = 0.005, OR 8.5 (95% CI 2.2-39.4)). In-hospital and 30-day mortality were 9% and 13.6%, respectively. Quick SOFA (p = 0.030, OR 5.4 (95% CI 1.2-24.9)) and Barthel Index <40% (p = 0.020, OR 4.8 (95% CI 1.3-18.2)) were associated with 30-day mortality by multivariate analysis. However, bacteremia was not associated with 30-day mortality (p = 0.154, OR 2.7 (95% CI 0.7-10.3)). Our study found that febrile community-acquired UTIs and elevated procalcitonin were risk factors for bacteremia. The outcomes in patients with bacteremia were slightly worse, but without significant differences in mortality.

Factors Associated with Acute Community-Acquired Pyelonephritis Caused by Extended-Spectrum β-Lactamase-Producing Escherichia coli

This study aimed to identify the factors associated with the presence of extended-spectrum ß-lactamase-(ESBL) in patients with acute community-acquired pyelonephritis (APN) caused by Escherechia coli (E. coli), with a view of optimising empirical antibiotic therapy in this context. We performed a retrospective analysis of patients with community-acquired APN and confirmed E. coli infection, collecting data related to demographic characteristics, comorbidities, and treatment. The associations of these factors with the presence of ESBL were quantified by fitting multivariate logistic models. Goodness-of-fit and predictive performance were measured using the ROC curve. We included 367 patients of which 51 presented with ESBL, of whom 90.1% had uncomplicated APN, 56.1% were women aged ≤55 years, 33.5% had at least one mild comorbidity, and 12% had recently taken antibiotics. The prevalence of ESBL-producing E. coli was 13%. In the multivariate analysis, the factors independently associated with ESBL were male sex (OR 2.296; 95% CI 1.043-5.055), smoking (OR 4.846, 95% CI 2.376-9.882), hypertension (OR 3.342, 95% CI 1.423-7.852), urinary incontinence (OR 2.291, 95% CI 0.689-7.618) and recurrent urinary tract infections (OR 4.673, 95% CI 2.271-9.614). The area under the ROC curve was 0.802 (IC 95% 0.7307-0.8736), meaning our model can correctly classify an individual with ESBL-producing E. coli infection in 80.2% of cases.

Hospitalization for urinary tract infections in Japan, 2010-2015: a retrospective study using a national inpatient database

BACKGROUND

Urinary tract infections (UTI) are common and can have severe consequences. However, there are few recent large-scale studies about them. We aimed to determine the incidence of hospitalization for UTI and to elucidate patient characteristics, clinical practice, and clinical outcomes by drawing on a Japanese nationwide database.

METHODS

This was a retrospective observational study using a national database that covers half the acute care inpatients in Japan. Patients aged ≥ 15 years who were hospitalized for UTI were eligible. We did not include patients with lower UTI such as cystitis. We investigated the annual number of patients hospitalized in Japan, those patients' characteristics, and risk factors for in-hospital mortality.

RESULTS

We identified 232,396 eligible patients from 31 million records of discharge between April 2010 and March 2015. The average age was 73.5 years and 64.9% of patients were female. The estimated annual number of hospitalizations because of UTI was 106,508. The incidence was 6.8 per 10,000 for men and 12.4 for women. The median medical care cost was 4250 USD. In-hospital mortality was 4.5%. Risk factors of poor survival included male sex, older age, lower bed capacity, non-academic hospital, admission in winter, higher Charlson Comorbidity Index score, low body mass index, coma on admission, ambulance use, disseminated intravascular coagulation, sepsis, renal failure, heart failure, cerebrovascular diseases, pneumonia, malignancies, use of anti-diabetic drugs, and use of corticosteroid or immunosuppressive drugs.

CONCLUSIONS

We found that older patients of both sexes accounted for a significant proportion of those hospitalized for UTI. The clinical and economic burden of UTI is considerable.

Trends in urinary tract infection hospitalization in older adults in Spain from 2000-2015

Objective

To analyze trends in urinary tract infection hospitalization (cystitis, pyelonephritis, prostatitis and non-specified UTI) among patients over 65 years in Spain from 2000–2015.

Methods

We conducted a retrospective observational study using the Spanish Hospitalization Minimum Data Set (CMBD), with codifications by the International Classification of Diseases (ICD-9). We collected data on sex, age, type of discharge, main diagnosis, comorbid diagnosis, length of stay, and global cost. All the hospitalizations were grouped by age into three categories: 65–74 years old, 75–84 years old, and 85 years old and above. In the descriptive statistical analysis, crude rates were defined as hospitalizations per 1,000 inhabitants aged ≥65. To identify trends over time, we performed a Joinpoint regression.

Results

From 2000–2015, we found 387,010 hospitalizations coded as UTIs (54,427 pyelonephritis, 15,869 prostatitis, 2643 cystitis and 314,071 non-specified UTI). The crude rate of hospitalization for UTIs between 2000 and 2015 ranged from 2.09 in 2000 to 4.33 in 2015 Rates of hospitalization were higher in men than in women, except with pyelonephritis. By age group, higher rates were observed in patients aged 85 years or older, barring prostatitis-related hospitalizations. Joinpoint analyses showed an average annual percentage increase (AAPC) in incidence rates of 4.9% (95% CI 3.2;6.1) in UTI hospitalizations. We observed two joinpoints, in 2010 and 2013, that found trends of 5.5% between 2000 and 2010 (95% CI 4.7;6.4), 1.5% between 2010 and 2013 (95% CI -6.0;9.6) and 6.8% between 2013 and 2015 (95% CI -0.3;14.4).

Conclusions

The urinary infection-related hospitalization rate in Spain doubled during the period 2000–2015. The highest hospitalization rates occurred in men, in the ≥85 years old age group, and in non-specified UTIs. There were increases in all types of urinary tract infection, with non-specified UTIs having the greatest growth. Understanding these changing trends can be useful for health planning.

Determinants of pyelonephritis onset in patients with obstructive urolithiasis

BACKGROUND

Acute obstructive pyelonephritis due to urolithiasis represents a medico-surgical emergency that can lead to life-threatening complications. There are still no established factors that reliably predict progression toward acute pyelonephritis in patients presenting with a simple renal colic.

OBJECTIVE

To investigate clinical and paraclinical factors that are associated with the onset of acute obstructive pyelonephritis.

METHODS

Patients presenting to the emergency department for renal colic with obstructive urolithiasis on imaging were enrolled in the study. Demographic data, vital signs, medical comorbidities, blood test results, urinalysis, and radiological findings were recorded. Obstructive pyelonephritis was defined by the presence of two or more of the following criteria: fever, flank pain or costovertebral angle tenderness, and a positive urine culture.

RESULTS

Seventeen patients out of 120 presenting with renal colic, were diagnosed with acute obstructive pyelonephritis (14%). Parameters that were associated with the onset of obstructive pyelonephritis were: diabetes (p = 0.03), elevated CRP (p = 0.01), stone size (>5 mm) (p = 0.03), dilatation of renal pelvis (p = 0.01), peri-renal fat stranding (p = 0.02), and positive nitrites on urinalysis (p < 0.01). Hyperleukocytosis, acute kidney injury, multiple stones, pyuria (>10/mm³), hypertension, and were not associated with the onset of obstructive pyelonephritis.

CONCLUSION

This study showed that known diabetic status, elevated CRP, positive urine nitrites, stone size (>5 mm), pyelic dilatation, and peri-renal fat stranding were associated with the onset of pyelonephritis in patients presenting to the emergency department with obstructive urolithiasis.

Urosepsis and the urologist!

Introduction:

Sepsis is a life-threatening organ dysfunction that is caused by a dysregulated host response to the infection. Urosepsis contributes up to 25% of all sepsis cases. An important part of the management of urosepsis is to rule out possible surgical causes such as urolithiasis, obstructive uropathy, or abscess formation along the urogenital tract.

Objective:

The aim of this study is to look at whether urological conditions and recent urological surgery contribute significantly to all patients admitted with urosepsis.

Methods:

A total of 2679 urine cultures and 654 blood cultures performed in Connolly Hospital Emergency Department were reviewed between 2016 and 2018. Patients were included if they had a matching urine culture and blood culture performed within 24 hours of admission. A retrospective chart review was performed for all patients included in the study.

Results:

Our study included 85 patients admitted with urosepsis between 2016 and 2018. The average age was 70.3 years (21–100 years), in which 61% (n = 52) of patients were female, 18% (n = 16) had a long-term indwelling catheter, 11.8% (n = 10) were admitted as urosepsis with a urological condition. The most common urological condition predisposing patients to urosepsis in this study was bladder outlet obstruction secondary to benign prostatic hyperplasia. A total of 4.7% (n = 4) of patients died during their admission. The complications as a result of urosepsis included a prostatic abscess, a psoas abscess, an ileus, an infected cyst, and 1 case of emphysematous pyelonephritis.

Conclusion:

In this study, the majority of patients admitted with urosepsis did not have an underlying urological condition or recent urological instrumentation. Clinicians should be aware of potential complications as a result of a urosepsis.

Clinical and computed tomography factors associated with sepsis in women with clinically uncomplicated pyelonephritis

OBJECTIVE

Sepsis is major determinants of prognosis in acute pyelonephritis (APN). This study aimed to assess factors associated with the development of sepsis among patients with clinically uncomplicated APN.

SUBJECTS AND METHODS

We examined 463 patients presenting to our hospital without complications. We assessed clinical factors including demographic and laboratory features. Renal and extrarenal features on computed tomography (CT) were also analyzed. Risk factors of sepsis are assessed.

RESULTS

The study included 361 patients without (78.0%) and 102 patients with sepsis (22.0%). Crude and attributable mortality rates were 3.9% and 2.0% versus 1.4% and 0.6%, respectively, among patients with and without sepsis. Clinical risk factors for sepsis were age >65 years (odds ratio [OR] 1.79, P = 0.02), absence of flank pain (OR 1.59, P = 0.04), absence of costovertebral tenderness (OR 1.89, P = 0.03), diabetes mellitus (OR 2.25, P = 0.02), bacteremia (OR 2.8, P = 0.01), C-reactive protein level >100 mg/L (OR 1.42, P = 0.02), and lack of previous APN history (OR 1.76, P = 0.04). APN grade IV (OR 3.16, P = 0.01), high grade hydronephrosis (OR 1.50, P = 0.03), diffuse peritoneal thickening (OR 4.12, P = 0.01), and acute interstitial pulmonary edema (OR 3.73, P = 0.01) were the CT features predictive of septic shock.

CONCLUSIONS

Although uncomplicated APN was largely non-fatal, several clinical and CT features could lead to sepsis. Our findings may be useful for predicting sepsis risk and deciding whether intravenous antibiotic treatment and intensive management should be initiated for uncomplicated APN.

Microbiological Features and Clinical Factors Associated with Empirical Antibiotic Resistance in Febrile Patients with Upper Urinary Tract Calculi

BACKGROUND

To investigate the clinical and microbiological features of febrile patients with upper urinary tract calculi and factors that affect empirical antibiotic resistance.

METHODS

A retrospective analysis was performed on 203 febrile patients hospitalized between January 2011 and December 2016 with antibiotic treatment for urinary tract infections and upper urinary tract calculi at three institutions. We collected and analyzed data, including patients' age, sex, body mass index, underlying diseases, stone-related factors, and the results of urine and blood culture examinations and antibiotic sensitivity tests.

RESULTS

The male-to-female ratio was 1:2.3. Bacteria were identified in 152 of the 203 patients (74.9%). The most commonly cultured microorganisms included Escherichia coli (44.1%), followed by Enterococci spp. (11.8%), Proteus spp. (8.6%), Streptococcus agalactiae (6.6%), Klebsiella spp. (5.3%), Pseudomonas spp. (4.6%), coagulase-negative Staphylococcus (4.0%), Staphylococcus epidermidis (4.0%), Serratia spp. (2.6%), Enterobacter spp. (0.7%), Acinetobacter spp. (0.7%), and mixed infections (7.2%). Cultured bacterial species showed sex-specific differences. Multivariate analysis revealed that calculi's multiplicity was an independent predictive factor for quinolone resistance (P = 0.008). Recurrent infections were a significant predictor of cefotaxime resistance during multivariable analysis (P = 0.041).

CONCLUSION

Based on the present study results, quinolone was not recommended as the empirical treatment in febrile patients with upper urinary tract calculi. Combination antibiotic therapy is recommended in cases of recurrent infections due to the possible occurrence of cefotaxime resistance.

Evaluation of prognostic value of MEDS, MEWS, and CURB-65 criteria and sepsis I and sepsis III criteria in patients with community-acquired infection in emergency department

Background:

Early and effective treatment of patients with sepsis requires early recognition in emergency department and understanding the severity of the disease. Many studies have been conducted for this purpose, and many of scoring systems have been developed that provide early recognition of these patients and show their severity.

Objectives:

The aim of this study is to evaluate the efficacy of the scoring systems used to determine the mortality of patients with infections admitted in emergency department.

Methods:

In all, 400 patients who admitted to Uludağ University Hospital Emergency Department were prospectively included in this study. In addition to Systemic Inflammatory Response Syndrome score, Quick SOFA score, Mortality in Emergency Department Sepsis score, Modified Early Warning Score, and Charlson Comorbidity Index score in all patients, CURB-65 score was calculated in the patients diagnosed with pneumonia. It has been aimed to determine the power of these scores’ predictive mortality rates and their superiority to each other.

Results:

It was found that Mortality in Emergency Department Sepsis score and Quick SOFA score could be used with similar efficacy (respectively p = 0.761 and p = 0.073) in determining early mortality in emergency department (5th and 14th days) and that MEDS score was more effective (p < 0.001) in predicting the 28th-day mortality. While these recommendations were valid in patients diagnosed with pneumonia, it was determined that CURB-65 score could also be used to estimate 5th-, 14th-, and 28th-day mortalities (respectively, for the 5th day, p = 0.894 and p = 0.256; for the 14th day, p = 0.425 and p = 0.098; and for the 28th day, p = 0.095 and p = 0.158). The power of Systemic Inflammatory Response Syndrome score, previously used to identify sepsis, in predicting mortality was detected to be lower.

Conclusion:

Mortality in Emergency Department Sepsis score and Quick SOFA score could be used with similar efficacy in determining early mortality in emergency department. However, if you want to predict 28th-day mortality rate, it can be better to use Mortality in Emergency Department Sepsis score or CURB-65 (in patients diagnosed with pneumonia).

Risk factors for uroseptic shock in hospitalized patients aged over 80 years with urinary tract infection

Background

The purpose of this study was to compare clinical characteristics and outcomes in individuals of different age groups with urinary tract infection (UTI), and to identify the relationships among advanced age and uroseptic shock.

Methods

This retrospective study compared clinical characteristics and outcomes in patients in different age groups with UTI and identified relationships between advanced age and uroseptic shock among hospitalized patients with UTI in an acute hospital care setting from January 2006 to October 2018. Patients were divided into young (age below 65 years), old (65–80 years), and very old (above 80 years) groups.

Results

Of 1,043 participants, 269 (25.8%) were very old and 200 (19.2%) developed uroseptic shock. Very old age [odds ratio (OR) 1.99, 95% confidence interval (CI): 1.25–3.19, P=0.004], male (OR 1.54, 95% CI: 1.07–2.24, P=0.022), presented flank pain (OR 1.54, 95% CI: 1.05–2.24, P=0.025), congestive heart failure (CHF) (OR 2.54, 95% CI: 1.27–5.06, P=0.008), acute kidney injury (AKI) (OR 4.19, 95% CI: 2.78–6.30, P<0.001), bacteremia (OR 1.78, 95% CI: 1.25–2.53, P=0.001), and multiple drug-resistant (MDR) bacteria (OR 1.43, 95% CI: 1.02–2.00, P=0.039) were associated with an increased risk of uroseptic shock in patients with UTI. In very old patients with UTI, bacteremia (OR 2.54, 95% CI: 1.38–4.69, P=0.003) and AKI (OR 4.37, 95% CI: 2.15–8.90, P<0.001) were independently associated with uroseptic shock.

Conclusions

Very old patients with UTI had a higher risk of developing uroseptic shock than younger patients. Bacteremia was an independent risk factor for uroseptic shock in very old patients with UTI.

Management of acute pyelonephritis in the emergency department observation unit

INTRODUCTION

This study aimed to assess the effectiveness of the emergency department observation unit (EDOU) for patients with acute pyelonephritis in a Singapore tertiary academic medical centre.

METHODS

We reviewed the clinical records of consecutive patients who presented with pyelonephritis between 1 July 2012 and 31 October 2014 to collect information on demographics, symptoms, signs, laboratory and radiological results, treatment, and clinical outcomes.

RESULTS

Of 459 emergency department (ED) patients who were identified as having pyelonephritis, 164 (35.7%) were managed in the EDOU. Successful management in the EDOU was achieved in 100 (61.0%) patients. Escherichia coli was the predominant (64.6%) micro-organism in urine cultures and was positive in 106 patients. Patients diagnosed with acute pyelonephritis who were successfully managed in the EDOU had a lower incidence of nausea (32.0% vs. 60.9%, p < 0.001) and vomiting (15.0% vs. 50.0%, p < 0.001) compared to those who were not successful.

CONCLUSION

EDOU is useful for both observation and treatment of patients with acute pyelonephritis. Urine cultures are sufficient for the identification of the culprit micro-organism. Patients who present with prominent symptoms of vomiting should have routine administration of antiemetics, while consideration for second-line antiemetics is recommended for those with persistent symptoms.

Management of Febrile Urinary Tract Infection With or Without Bacteraemia in Children: A French Case-Control Retrospective Study

Background: Febrile urinary tract infections (FUTIs) are common among children, and are associated with a bacteraemia between 4 and 7% of cases. No data is available concerning the management of children with a bacteraemic FUTI. Objectives: To compare the antibiotic treatment (parenteral and total duration) among children with bacteraemic and non-bacteraemic FUTIs, and the mean hospital length of stay (LOS); to describe clinical, microbiological and imaging features of children with bacteraemic and non-bacteraemic FUTIs and observed management modifications when the blood culture was positive. Methods: A retrospective case-control study between 2009 and 2015 at Robert Debré's Pediatric Emergency Department (Paris, France). Children with a bacteraemic FUTI were included and matched for age and sex with two children with a non-bacteraemic FUTI. Results: We included 50 children with a bacteraemic FUTI matched to 100 children with a non-bacterameic FUTI. The mean duration of parenteral antibiotics was longer for bacteraemic children (6.7 vs. 4.0 days, p < 0.001) but this difference was only significant in children > 28 days-old. The mean total duration of antibiotic was similar (11.3 vs. 11.6 days, p = 0.61). The mean LOS was longer for bacteraemic children (5.1 vs. 2.0 days, p < 0.001) but this difference was only significant in children > 28 days-old. A positive blood culture changed the management in 66% of patients. Clinical features at presentation were comparable. Bacteraemic patients had a higher procalcitonin (p = 0.006) and C-reactive protein (p = 0.01), lower mean lymphocyte count (p < 0.001). Conclusions: A bacteraemic FUTI in children induced a longer duration of parenteral antibiotic treatment, a longer hospitalization in children > 28 days-old, and a modification of management for 66% of patients.

Clinical impact of perinephric fat stranding detected on computed tomography in patients with acute pyelonephritis: a retrospective observational study

Perinephric fat stranding (PFS) is often detected on computed tomography (CT) in patients with acute pyelonephritis (APN). However, its clinical impact remains unclear. This study aimed to evaluate the clinical impact of PFS detected on CT in patients with APN. This retrospective observational study included patients with APN who underwent CT (median age, 79.5 years). Patients were classified into PFS (patients with PFS observed on CT) and non-PFS (patients without PFS observed on CT) groups, which were further classified into bacteraemia and non-bacteraemia groups. Clinical findings between the groups were compared. Among 194 patients who underwent CT, 111 (57.2%) patients demonstrated PFS. The rate of bacteraemia was significantly higher in the PFS group than in the non-PFS group (55.2 vs. 23.1%, p < 0.001). CT findings other than PFS were not associated with bacteraemia. The median peak body temperature was significantly higher in the PFS group than in the non-PFS group (38.8 vs. 38.5 °C, p < 0.001); however, the duration of fever and in-hospital mortality rates were not significantly different between the groups. Concordance between blood and urine culture results was observed in 75.0% of the patients; the presence of PFS was not different between patients with concordant and discordant results, regardless of the pre-treatment antibiotic used. Our findings suggest that the presence of PFS in patients with APN predicts bacteraemia; thus, clinicians should consider obtaining blood cultures if PFS is found on CT in patients with APN, even if the patients had received antibiotics prior to admission.

Acute Pyelonephritis: A Single-center Experience

Acute pyelonephritis (APN), although a common clinical entity, still not much is known about the clinical profile in the Indian scenario. We prospectively collected clinical, biochemical, and radiological data of patients hospitalized with a diagnosis of APN from March 2014 to June 2016. A total of 296 cases were included in the study. Mean age was 53.85 ± 9.78 years. Male to females ratio was 1.93:1. Among the risk factors recognized for complicated pyelonephritis (PN), diabetes mellitus (DM) (54.4%) was the most common factor followed by renal calculi (14.4%), benign prostatic hyperplasia (6.7%), immunocompromised state (3.3%), stricture urethra and meatal stenosis (3.3%), and neurogenic bladder (2%). Urinary culture was negative in 153 (51.7%) and positive in 143 patient (48.3%). Most common organism isolated was Escherichia coli (29.7%), followed by Klebsiella pneumoniae (5.4%), pseudomonas (5.4%), Enterococcus (4.4%), and Proteus in 10 (3.4%). Serum creatinine of more than 1.5 mg/dl at admission was seen in 96.3% patients; 40% of them had underlying chronic kidney disease with DM being the most common. Multiorgan dysfunction either at admission or during the course in hospital stay was seen in 31.8% patients. Twelve (2%) had emphysematous PN. Six patients had Class II, 4 had Class III, 1 with Class I, and another with Class IV. A total of 18 deaths were noted (6.1%). Hemoglobin <10 g/dl, serum creatinine at admission >1.5 mg/dl, HbA1c% >10%, and immunosuppression had statistically significant association with the development of multiorgan dysfunction on univariate analysis, but on multivariate analysis, only hemoglobin, HbA1c%, and immunosuppression reached statistical significance. Even with attributable risk of mortality, only hemoglobin, HbA1c%, and immunosuppression reached statistical significance on multivariate analysis. HbA1c% adds to the predictive parameters to recognize at-risk patients to intensify the treatment and avoid complications.

Pyelonephritis in persons after age 50 as a clinical marker of urogenital cancer

OBJECTIVES

Urinary tract infections have been linked with urinary tract cancer, but the association remains controversial. We examined whether pyelonephritis is a clinical marker of urogenital cancer.

METHODS

We used Danish medical databases to create a population-based cohort of patients with an incident hospital-based pyelonephritis diagnosis during 1994-2013. Follow-up for cancer began at pyelonephritis diagnosis and ended on 30 November 2013. We restricted the cohort to patients older than 50 years, as urogenital cancer risk in the younger population is low. We calculated the absolute risk of urogenital cancer and the standardized incidence ratio (SIR) comparing risk observed in pyelonephritis patients to risk expected in the general population of Denmark.

RESULTS

Among 15 070 patients with pyelonephritis, we observed 197 urinary tract cancers and 374 genital organ cancers over a 20-year follow-up period. The absolute risk of urogenital cancer was 1.5% 6 months after a pyelonephritis diagnosis, and the cumulative risk was 3.0% at 5 years. During the first 6 months following a pyelonephritis diagnosis, the SIR of urogenital cancer was 8.56 (95% CI 7.49-9.75). Between 6 and 12 months following this diagnosis, the SIR was 1.75 (95% CI 1.26-2.35), and beyond 1 year the SIR was approximately unity for most cancers. Notably, the SIR for bladder cancer among women remained elevated beyond 1 year of follow-up.

CONCLUSIONS

Patients presenting with a hospital-based diagnosis of pyelonephritis had a higher 6-month risk of urogenital cancer than expected. However, causation cannot be inferred because of the study design.

The clinical impact of bacteremia on outcomes in elderly patients with pyelonephritis or urinary sepsis: A prospective multicenter study

Background

Bacteremia is common in severe urinary infections, but its influence on the outcomes is not well established. The aim of this study was to assess the association of bacteremia with outcomes in elderly patients admitted to hospital with pyelonephritis or urinary sepsis.

Methods

This prospective muticenter observational study was conducted at 5 Spanish hospitals. All patients aged >65 years with pyelonephritis or urinary sepsis admitted to the departments of internal medicine and with urine and blood cultures obtained at admission to hospital were eligible. Transfer to ICU, length of hospital stay, hospital mortality and all cause 30-day mortality in bacteremic and non-bacteremic groups were compared. Risk factors for all cause 30-day mortality was also estimated.

Results

Of the 424 patients included in the study 181 (42.7%) had bacteremia. Neither transfer to ICU (4.4% vs. 2.9%, p = 0.400), nor length of hospital stay (9.7±4.6 days vs. 9.0±7.3 days, p = 0.252), nor hospital mortality (3.3% vs. 6.2%, p = 0.187), nor all cause 30-day mortality (9.4% vs. 13.2%, p = 0.223) were different between bacteremic and non-bacteremic groups. By multivariate analysis, risk factors for all cause 30-day mortality were age (OR 1.05, 95% CI 1.00–1.10), McCabe index ≥2 (OR 10.47, 95% CI 2.96–37.04) and septic shock (OR 8.56, 95% CI 2.86–25.61); whereas, bacteremia was inversely associated with all cause 30-day mortality (OR 0.33, 95% CI 0.15–0.71).

Conclusions

In this cohort, bacteremia was not associated with a worse prognosis in elderly patients with pyelonephritis or urinary sepsis.

A Cohort Study of Risk Factors That Influence Empirical Treatment of Patients with Acute Pyelonephritis

The aim of the current study was to compare community-acquired acute pyelonephritis (CA-APN) with health care-associated acute pyelonephritis (HCA-APN), describe the outcomes, and identify variables that could predict antimicrobial susceptibility. We conducted an observational study that included all consecutive episodes of acute pyelonephritis (APN) in adults during 2014 at a Spanish university hospital. From each episode, demographic data, comorbidities, clinical presentation, microbiological data, antimicrobial therapy, and outcome were recorded. A multivariable logistic regression model was performed to define the variables associated with antimicrobial resistance. A total of 607 patients, 503 (82.9%) with CA-APN and 104 (17.1%) with HCA-APN, were included in the study. Patients with HCA-APN were older than patients with CA-APN (70.4 versus 50.6 years; P < 0.001) and had higher rates of previous urinary tract infections (UTIs) (56.5% versus 24.5%; P < 0.001) and previous antibiotic use (56.8% versus 22.8%; P < 0.001). Escherichia coli was more frequently isolated from patients with CA-APN than from patients with HCA-APN (79.9% versus 50.5%; P < 0.001). The rates of resistance of Escherichia coli strains from CA-APN patients versus HCA-APN patients were as follows: amoxicillin-clavulanic acid, 22.4% versus 53.2% (P = 0.001); cefuroxime, 7.7% versus 43.5% (P = 0.001); cefotaxime, 4.3% versus 32.6% (P < 0.001); ciprofloxacin, 22.8% versus 74.5% (P < 0.001); and co-trimoxazole, 34.5% versus 58.7% (P = 0.003). The site of acquisition, recurrent UTIs, and previous antibiotic use were independent risk factors for antimicrobial resistance. Relapse rates were significantly higher when definitive antimicrobial treatment was not adequate (37.1% versus 9.3% when definitive antimicrobial treatment was adequate; P < 0.001). Our study reflects the rise of resistance to commonly used antibiotics in acute pyelonephritis. In order to choose the adequate empirical antibiotic therapy, risk factors for resistance should be considered.

Factors associated with severe sepsis or septic shock in complicated pyelonephritis

Severe sepsis or septic shock are the main factors influencing the prognosis of acute pyelonephritis (APN). Our aim was to analyze factors associated with the development of severe sepsis or septic shock in a large sample of patients with acute complicated pyelonephritis (ACPN).This prospective observational study comprised 1507 consecutive patients aged 14 years or older who were admitted to a tertiary care hospital because of ACPN between 1997 and 2015. Covariates associated in univariate analysis with severe sepsis or septic shock were then analyzed by multivariate logistic regression.Of the 1507 patients, 423 (28.1%) fulfilled the criteria for severe sepsis or septic shock at the time of admission. Crude and attributable mortality at 30 days were 17.7% and 11.7% in patients with severe sepsis or septic shock versus 1.7% and 0.6% in patients without severe sepsis or septic shock, P < .0001 and P < .0005, respectively. An age > 65 years, urinary instrumentation in the previous 2 weeks, the lack of mictional syndrome or costovertebral tenderness, an ectasia ≥ grade II, and bacteremia were independent risk factors associated with severe sepsis or septic shock.The prevalence of severe sepsis and septic shock in patients with ACPN is high. Some factors associated with severe sepsis are easy to identify in any emergency department. The information provided here could be useful when deciding which patients should be admitted to receive immediate treatment.

Hospitalization for community-acquired febrile urinary tract infection: validation and impact assessment of a clinical prediction rule

Background

There is a lack of severity assessment tools to identify adults presenting with febrile urinary tract infection (FUTI) at risk for complicated outcome and guide admission policy. We aimed to validate the Prediction Rule for Admission policy in Complicated urinary Tract InfeCtion LEiden (PRACTICE), a modified form of the pneumonia severity index, and to subsequentially assess its use in clinical practice.

Methods

A prospective observational multicenter study for model validation (2004–2009), followed by a multicenter controlled clinical trial with stepped wedge cluster-randomization for impact assessment (2010–2014), with a follow up of 3 months. Paricipants were 1157 consecutive patients with a presumptive diagnosis of acute febrile UTI (787 in validation cohort and 370 in the randomized trial), enrolled at emergency departments of 7 hospitals and 35 primary care centers in the Netherlands.

The clinical prediction rule contained 12 predictors of complicated course. In the randomized trial the PRACTICE included guidance on hospitalization for high risk (>100 points) and home discharge for low risk patients (<75 points), in the control period the standard policy regarding hospital admission was applied. Main outcomes were effectiveness of the clinical prediction rule, as measured by primary hospital admission rate, and its safety, as measured by the rate of low-risk patients who needed to be hospitalized for FUTI after initial home-based treatment, and 30-day mortality.

Results

A total of 370 patients were included in the randomized trial, 237 in the control period and 133 in the intervention period. Use of PRACTICE significantly reduced the primary hospitalization rate (from 219/237, 92%, in the control group to 96/133, 72%, in the intervention group, p < 0.01). The secondary hospital admission rate after initial outpatient treatment was 6% in control patients and 27% in intervention patients (1/17 and 10/37; p < 0.001).

Conclusions

Although the proposed PRACTICE prediction rule is associated with a lower number of hospital admissions of patients presenting to the ED with presumptive febrile urinary tract infection, futher improvement is necessary to reduce the occurrence of secondary hospital admissions.

Trial registration

NTR4480 http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=4480, registered retrospectively 25 mrt 2014 (during enrollment of subjects).

Electronic supplementary material

The online version of this article (doi:10.1186/s12879-017-2509-3) contains supplementary material, which is available to authorized users.

Febrile urinary tract infections: pyelonephritis and urosepsis

PURPOSE OF REVIEW

Complicated infections of the urinary tract (UTI) including pyelonephritis and urosepsis are also called febrile UTI. This review describes insights from the literature on this topic since July 2014.

RECENT FINDINGS

Recent studies regarding risk factors and consequences of febrile UTI confirmed existing knowledge. It remains difficult to obtain insight into the epidemiology of febrile UTI because urine and blood cultures are frequently missing. The relationship between host and virulence factors of Escherichia coli was further explored showing that less virulent strains can cause infection in immunocompromised patients. In contrast to obstructive uropathy, diabetes, and being older, neutropenia was not a risk factor for lower UTI or urosepsis. A randomized controlled trial revealed that ceftolozane-tazobactam was marginally superior to levofloxacin as treatment for complicated UTI. Case series supported the notion that xanthogranulomatous and emphysematous pyelonephritis are more common in diabetic patients and that drainage or surgery is often required.

SUMMARY

Neutropenia was not a risk factor for lower UTI or urosepsis. When local resistance percentages to the frequently prescribed fluoroquinolones are high, the combination of ceftolozane-tazobactam may be an alternative as treatment for complicated UTI. Xanthogranulomatous and emphysematous pyelonephritis need to be considered in diabetic patients presenting with UTI symptoms.

Clinical relevance of seasonal changes in the prevalence of ureterolithiasis in the diagnosis of renal colic

Ureterolithiasis is one of the most frequently diagnosed urologic diseases worldwide. Its annual incidence in Japan increased three-fold from 1965 to 2005. Ureterolithiasis incidence is affected by numerous factors, including race, sex, body weight, fluid intake, and climate. Here, we aimed to address the latter by considering the effect of seasonal variation on stone incidence and incorporating this information into a predictive model for differential diagnosis of ureteral stone from other conditions with similar presentations. We retrospectively identified 491 patients in our emergency department computer database who complained of back, flank, or lower abdominal pain during 2007-2015. Among them, 358 had stones, as confirmed by computerized tomography or plain abdominal X-ray of kidney-ureter-bladder. We also charted the mean ambient temperatures in our city for a year. The cases of ureteral stones paralleled the ambient temperatures, peaking during the hottest weather. Univariate analysis identified 13 factors associated with ureteral stones. Multivariate analysis narrowed the number to eight: age <60 years, male sex, short duration of pain (<6 h), nausea/vomiting, hydronephrosis, hematuria, history of urinary stone(s), and summer (July-September in Japan). Pain appearing during summer was nine times more likely to be due to a ureteral stone than was pain appearing during other seasons. We incorporated the eight variables identified into a predictive logistic regression model, which yielded good prediction of ureteral stones. Awareness that hot weather is associated with increased incidence of ureterolithiasis could facilitate differential diagnosis, and our prediction model could be useful for screening for ureterolithiasis.

Reverse kinetics of angiopoietin-2 and endotoxins in acute pyelonephritis: Implications for anti-inflammatory treatment?

Based on former studies showing an antagonism between angiopoietin-2 (Ang-2) and bacterial endotoxins (LPS), we investigated the role of Ang-2 as immunomodulatory treatment. At first, kinetics of circulating LPS in Gram-negative pyelonephritis developing after urinary obstruction was studied. Serum LPS, interleukin (IL)-6 and Ang-2 were measured in 25 patients with acute pyelonephritis and sepsis before and after removal of the obstruction performed either with insertion of a pigtail catheter (n=12) or percutaneous drainage (n=13). At a second stage, Ang-2 was given as anti-inflammatory treatment in 40 rabbits one hour after induction of acute pyelonephritis by ligation of the ureter at the level of pelvo-ureteral junction and upstream bacterial inoculation. Survival was recorded; blood mononuclear cells were isolated and stimulated for the production of tumour necrosis factor-alpha (TNFα). The decrease in circulating LPS was significantly greater among patients undergoing drainage than pigtail insertion. This was accompanied by reciprocal changes of Ang-2 and IL-6. Treatment with Ang-2 prolonged survival from Escherichia coli pyelonephritis despite high levels of circulating LPS. When Ang-2 was given as treatment of Pseudomonas aeruginosa pyelonephritis, sepsis-induced decrease of TNFα production by circulating mononuclear cells was reversed without an effect on tissue bacterial overgrowth. It is concluded that Ang-2 and LPS follow reverse kinetics in acute pyelonephritis. When given as experimental treatment, Ang-2 prolongs survival through an effect on mononuclear cells.