Postgraduate Medicine
ISSN: 0032-5481 (Print) 1941-9260 (Online) Journal homepage: http://www.tandfonline.com/loi/ipgm20
Urinary Tract Infection Jay P. Sanford To cite this article: Jay P. Sanford (1975) Urinary Tract Infection, Postgraduate Medicine, 58:3, 167-173, DOI: 10.1080/00325481.1975.11714149 To link to this article: http://dx.doi.org/10.1080/00325481.1975.11714149
Published online: 07 Jul 2016.
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Citing articles: 1 View citing articles
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=ipgm20 Download by: [Australian Catholic University]
Date: 08 August 2017, At: 13:41
co sder • What presenting symptoms distinguish bacteriuria from acute urethral syndrome? • What are three important goals of management of urinary tract infection? • What is the prognosis for patients with recurrent urinary tract infection and no obstructive uropathy?
JAY P. SANFORD, MD
Downloaded by [Australian Catholic University] at 13:41 08 August 2017
University of Texas Southwestern Medical School at Dallas
Urinary Tract Infection Dr. Sanford has chosen an approach to the problem of urinary tract infection that most of us can appreciate. He describes a hypothetical patient and poses the questions that must be answered in managing patients with urinary tract symptoms and infection. He points out that we really do not know how to determine which patients will subsequently have chronic pyelonephritis. Until we do, Dr. Sanford's suggested guidelines will be helpful in managing the patient with acute or chronic urinary tract infection.-HCN
Dysuria, the major symptom suggesting infection of the urinary tract, is among the most cornmon complaints for which patients seek medical advice. In a survey 1 of 2,933 women 20 to 64 years of age, 21.8% said that they had had dysuria during the previous year. Nearly half of these women had consulted physicians. The problems posed by patients with urinary tract symptoms and infection can be brought into focus by the following illustrative case and the questions it raises. lllustrative Case
A 34-year-old housewife awakens with urgency and terminal dysuria. The symptoms are not incapacitating, and since she had similar symptoms two years earlier which subsided, she does not
Vol. 58 • No. 3 • September 1975 • POSTGRADUATE MEDICINE
seek medical attention. Six days later the symptoms have worsened and she notes pain in the left flank and fever. Because of the severity of symptoms, she goes to a hospital emergency room. Salient findings include a temperature of 101 F, blood pressure of 108/76 mm Hg, and minimal tenderness in the region of the left costovertebral angle. A clean-voided urine specimen shows "trace" protein, no sugar, "numerous" white blood cells per high-power field (WBC/hpf), and a few bacilli. In assuming management of this case, the physician must answer the following questions: 1. Should acute management include culture of a urine specimen obtained by catheterization or suprapubic bladder aspiration, culture of a cleanvoided specimen, or no culture at aU since the patient has obvious infection and this is the first recent episode? 2. If antimicrobial therapy is elected, should the physician prescribe a sulfonamide, an agent whose effectiveness is limited to urinary tract infections (eg, nitrofurantoin or nalidixic acid), or an antibiotic? 3. How long should the patient be treated, and should medication be prescribed initially for two or ten days? 4. Should an intravenous urogram and voiding cystogram be done? Sulfisoxazole, 1 gm every six hours, is pre-
167
TABLE 1. PRESENTING SYMPTOMS OF URINARY TRACT INFECTION IN 130 PATIENTS 2
Symptom
With bacteriuria Without bacteriuria* (77 patients) (53 patients) Number Percent
Fe ver Dysuria Hematuria Frequency Loin pain
Downloaded by [Australian Catholic University] at 13:41 08 August 2017
Lower abdominal pain
28 71 18 70 26 49
36 92 23 91 34 64
Number
Percent
8
15
38
72
7 50 17 34
13
94 32 64
*Acute urethral syndrome.
scribed. The patient becomes asymptomatic within one day of beginning therapy, and two days later the initial urine culture is reported as showing "no growth" ( < 1,000 organisms/ml). The physician now must answer the following questions: 1. Should sulfisoxazole therapy be continued or stopped? 2. If tteatment is stopped and the original prescription was for eighty 0.5-gm tablets, what should the patient be advised to do with the remaining tablets? Assuming that the initial urine culture had been reported as showing 44 million colonies/ml of Escherichia coli sensitive to ali agents tested, the physician would have to answer the following questions: 1. How long should antimicrobial therapy be continued? 2. Should a urine culture be repeated and, if so, when? 3. If a repeat urine culture is positive but the patient is asymptomatic, what should be done? One month after initial onset of symptoms the patient remains asymptomatic, repeat urine culture on a clean-voided specimen shows "no growth," and an intravenous urogram and voiding cystourethrogram are normal. The physician now must answer the following questions: 1. What is the anticipated course and prognosis? 2. Do the two previous episodes of probable urinary tract infection indicate a likelihood of chronic pyelonephritis?
168
3. Is long-term antimicrobial treatment indicated? 4. Is hypertension or progressive renal insufficiency likely to develop? Goals of Management
Before reviewing the available data, it may be advantageous to summarize briefly the goals of management: (1) prevention of progressive renal damage, if such is likely, (2) eradication of infection, with relief of the concomitant complications of toxicity and of possible dissemination of the infection, and (3) relief of symptoms. The last goal may be achieved more easily than the fust two and may require the use of different regimens. Natural History of Urinary Tract Infection
A review of current knowledge of the natural history of urinary tract symptoms and infection in the adule may contribute to the development of more rational approaches to this common problem. lt has long been recognized that many patients with complaints of frequency and dysuria have "negative" urine cultures. In a classic study, Gallagher and associates2 collected data on a group of 130 patients seen over a period of eight months in the offices of eight physicians in Auckland, New Zealand. A qualified nurse obtained from each patient a catheterized specimen of urine which was immediately refrigerated and within one hour was examined and cultured. The sttiking finding was "insignificant" bacteriuria ( < 10,000 organisms/ml) in 53 (41%) of the subjects. Even more important, however, was the observation chat 41 (32%) of these individuals had sterile urine cultures. In the patients without bacteriuria, the investigators termed the clinical entity "acute urethral syndrome." A comparison of the presenting symptoms in individuals with bacteriuria and those with acute urethral syndrome reveals no significant distinguishing characteristics (table 1). Loin pain, or costovertebral tenderness, occurred with comparable frequency in both groups. Significant pyuria ( > 5 WBC/hpf) was present in 10 (13%) of the 77 urine specimens from patients with bacteriuria as compared with 7 (13%) of 53 specimens from patients without bacteriuria. Subsequent studies have confirmed these observations. Gallagher and associates2 felt that many cases of acute urethral syndrome were due to infection confined to the urethra and surrounding glands. However, the etiology of the acute urethral syndrome, especially in chose patients who do not have pyuria, remains unknown. Studies in progress
POSTGRADUATE MEDICINE • September 1975 • Vol. 58 • No. 3
Downloaded by [Australian Catholic University] at 13:41 08 August 2017
Figure 1. Natural history of pyelonephritis illustrated hypothetically. From Jawetz E: Urinary tract infections. ln Aisner M, et al (Editors): Disease-A-Month, Nov 1954. © 1954 by Year Book Medical Publishers, lnc, Chicago. Used by permission.
have included searches for viral agents, chlamydiae (TRIC agents), gonococci, and bacterial spheroplasts. In patients with pyuria and other symptoms who have sterile cultures, it is essential to consider tuberculosis, fungal disease of the kidneys, and calculus disease. Although it remains to be proved, patients with the acute urethral syndrome who have pyuria are likely to benefit from antibacterial therapy, while those who do not have pyuria are not. Recognition of the acute urethral syndrome is important. Because this syndrome frequendy is not recognized, many women who do not have bacterial urinary tract infection are studied extensively, treated with cosdy and perhaps toxic antimicrobial agents, subjected to various invasive urologie procedures, and diagnosed as having "recurrent and chronic pyelonephritis." Since the classic work of Weiss and Parker,3 the occurrence of chronic renal disease as a consequence of pyelonephritis has been weil recognized. On the basis of numerous observations, it has been postulated that pyelonephritis might be a disease continuum rather than being a
Vol. 58 • No. 3 • September 1975 • POSTGRADUATE MEDICINE
Figure 2. Kinetic relationship of acute and chronic bacterial pyelonephritis to chronic renal disease.
169
Locating the Site of Infection
JAY P. SANFORD
Downloaded by [Australian Catholic University] at 13:41 08 August 2017
Dr. Sanford was formerly professor of internai medicine, University of Texas Southwestern Medical School at Dallas. He is now dean of the School of Medicine, Uniformed Services University of the Health Sciences, Bethesda.
TABLE 2. METHODS AVAILABLE FOR LOCALIZATION OF INFECTION IN THE URINARY TRACT
Direct
Indirect
Ureteral catheterization
Titration of serum antibodies
Renal biopsy
Urine concentration test
Bladder washout technique 7
Determination of urinary enzyme excretion Detection of a nti body-coated bacteria in urine
series of apparendy unrelated episodes4 (figure 1). The concept of a disease continuum reflects a retrospective approach which may be applicable co individual experiences. The problem may be becter recognized from the epidemiologie standpoint, as illustrated in figure 2. The anatomie changes designared as pyelonephritis can be produced by a number of noninfectious causes; these will not be considered in this discussion. There is general agreement thar both acute and chronic pyelonephritis can lead to the development of chronic renal disease; the unanswered question is, How frequendy does this progression occur? Definition of these relationships is paramount in quantifying the problem. As an initial approach, the assumption would seem justified thar infection limited to the lower urinary tract will not direcdy cause chronic renal disease, except as a potential source for ascending infection. The majority of patients seeking medical care for urinary tract infections do so because of dysuria. How frequendy do such patients have bacreriuria and, if bacteriuria is present, renal parenchymal involvement?
170
Reeves and Brumfitt11 stated that the understanding of urinary tract infection will advance considerably when a simple and reliable method is available for localization. The methods now available are summarized in table 2. Direct methods-The most reliable method for localization has been the recovery of bacteria in ureteral urine obtained from the affected kidney. Stamey and associates 6 have used the technique of urereral catheterization extensively to differentiate berween pyelonephritis and lower urinary tract infection. More recendy, Fairley and associates7 have developed an ingenious bladder washout technique for obtaining the equivalent of ureteral urine without the need to pass a ureteral catheter. The bladder washout procedure has been used quite extensively, and results correlate weil with those of ureteral cathererization. Unforrunately, the bladder washout procedure involves urethral carheterization and is too cumbersome for routine use. Indirect methods-While antibody citers and changes in the ability to produce a concentrated urine are useful indicarors in groups of patients, exceptions are sufficiendy frequent to make these determinations of less value when applied to an individual. Thomas and associates8 have described another indirect technique, which is based on the detection of antibody-coated bacteria in urine. Jones and associates9 have demonstrated that the presence of antibody-coated bacteria correlates very well with renal localization by the bladder washout technique in women; however, in men with prostatic infection, antibody-coated bacteria may be detecred in the absence of renal involvement.10 Review and Summary of Data
Knowledge of the natural history of a disease is essential co its rational diagnosis and management. Yet at this rime, data relevant to the natural history of symptomatic urinary tract infections are both scanty and conflicting. Review of these data emphasizes the necessity for a simple, reliable method of localization of infection. Fairley and associates 11 studied 66 women who were seen by general practitioners for symptoms of acute urinary tract infection. They did cultures and bladder washout localization studies in those with bacteriuria. From their observations (table 3), as well as from the studies cited previously, the clinical problem of urinary tract symptoms and infection in adules may be sumrned up as follows: Dysuria occurs in approximately 20% of women each year, half of whom seek medical
POSTGRADUATE MEDICINE
o
5eptember 1975
o
Vol. 58
o
No. 3
TABLE 3. DISTRIBUTION OF SYMPTOMS OF ACUTE URINARY TRACT INFECTION IN && PATIENTS SEEN IN GENERAL PRACTICE"
Manifestations
Percent with no bacteriuria or
ISSN: 0032-5481 (Print) 1941-9260 (Online) Journal homepage: http://www.tandfonline.com/loi/ipgm20
Urinary Tract Infection Jay P. Sanford To cite this article: Jay P. Sanford (1975) Urinary Tract Infection, Postgraduate Medicine, 58:3, 167-173, DOI: 10.1080/00325481.1975.11714149 To link to this article: http://dx.doi.org/10.1080/00325481.1975.11714149
Published online: 07 Jul 2016.
Submit your article to this journal
View related articles
Citing articles: 1 View citing articles
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=ipgm20 Download by: [Australian Catholic University]
Date: 08 August 2017, At: 13:41
co sder • What presenting symptoms distinguish bacteriuria from acute urethral syndrome? • What are three important goals of management of urinary tract infection? • What is the prognosis for patients with recurrent urinary tract infection and no obstructive uropathy?
JAY P. SANFORD, MD
Downloaded by [Australian Catholic University] at 13:41 08 August 2017
University of Texas Southwestern Medical School at Dallas
Urinary Tract Infection Dr. Sanford has chosen an approach to the problem of urinary tract infection that most of us can appreciate. He describes a hypothetical patient and poses the questions that must be answered in managing patients with urinary tract symptoms and infection. He points out that we really do not know how to determine which patients will subsequently have chronic pyelonephritis. Until we do, Dr. Sanford's suggested guidelines will be helpful in managing the patient with acute or chronic urinary tract infection.-HCN
Dysuria, the major symptom suggesting infection of the urinary tract, is among the most cornmon complaints for which patients seek medical advice. In a survey 1 of 2,933 women 20 to 64 years of age, 21.8% said that they had had dysuria during the previous year. Nearly half of these women had consulted physicians. The problems posed by patients with urinary tract symptoms and infection can be brought into focus by the following illustrative case and the questions it raises. lllustrative Case
A 34-year-old housewife awakens with urgency and terminal dysuria. The symptoms are not incapacitating, and since she had similar symptoms two years earlier which subsided, she does not
Vol. 58 • No. 3 • September 1975 • POSTGRADUATE MEDICINE
seek medical attention. Six days later the symptoms have worsened and she notes pain in the left flank and fever. Because of the severity of symptoms, she goes to a hospital emergency room. Salient findings include a temperature of 101 F, blood pressure of 108/76 mm Hg, and minimal tenderness in the region of the left costovertebral angle. A clean-voided urine specimen shows "trace" protein, no sugar, "numerous" white blood cells per high-power field (WBC/hpf), and a few bacilli. In assuming management of this case, the physician must answer the following questions: 1. Should acute management include culture of a urine specimen obtained by catheterization or suprapubic bladder aspiration, culture of a cleanvoided specimen, or no culture at aU since the patient has obvious infection and this is the first recent episode? 2. If antimicrobial therapy is elected, should the physician prescribe a sulfonamide, an agent whose effectiveness is limited to urinary tract infections (eg, nitrofurantoin or nalidixic acid), or an antibiotic? 3. How long should the patient be treated, and should medication be prescribed initially for two or ten days? 4. Should an intravenous urogram and voiding cystogram be done? Sulfisoxazole, 1 gm every six hours, is pre-
167
TABLE 1. PRESENTING SYMPTOMS OF URINARY TRACT INFECTION IN 130 PATIENTS 2
Symptom
With bacteriuria Without bacteriuria* (77 patients) (53 patients) Number Percent
Fe ver Dysuria Hematuria Frequency Loin pain
Downloaded by [Australian Catholic University] at 13:41 08 August 2017
Lower abdominal pain
28 71 18 70 26 49
36 92 23 91 34 64
Number
Percent
8
15
38
72
7 50 17 34
13
94 32 64
*Acute urethral syndrome.
scribed. The patient becomes asymptomatic within one day of beginning therapy, and two days later the initial urine culture is reported as showing "no growth" ( < 1,000 organisms/ml). The physician now must answer the following questions: 1. Should sulfisoxazole therapy be continued or stopped? 2. If tteatment is stopped and the original prescription was for eighty 0.5-gm tablets, what should the patient be advised to do with the remaining tablets? Assuming that the initial urine culture had been reported as showing 44 million colonies/ml of Escherichia coli sensitive to ali agents tested, the physician would have to answer the following questions: 1. How long should antimicrobial therapy be continued? 2. Should a urine culture be repeated and, if so, when? 3. If a repeat urine culture is positive but the patient is asymptomatic, what should be done? One month after initial onset of symptoms the patient remains asymptomatic, repeat urine culture on a clean-voided specimen shows "no growth," and an intravenous urogram and voiding cystourethrogram are normal. The physician now must answer the following questions: 1. What is the anticipated course and prognosis? 2. Do the two previous episodes of probable urinary tract infection indicate a likelihood of chronic pyelonephritis?
168
3. Is long-term antimicrobial treatment indicated? 4. Is hypertension or progressive renal insufficiency likely to develop? Goals of Management
Before reviewing the available data, it may be advantageous to summarize briefly the goals of management: (1) prevention of progressive renal damage, if such is likely, (2) eradication of infection, with relief of the concomitant complications of toxicity and of possible dissemination of the infection, and (3) relief of symptoms. The last goal may be achieved more easily than the fust two and may require the use of different regimens. Natural History of Urinary Tract Infection
A review of current knowledge of the natural history of urinary tract symptoms and infection in the adule may contribute to the development of more rational approaches to this common problem. lt has long been recognized that many patients with complaints of frequency and dysuria have "negative" urine cultures. In a classic study, Gallagher and associates2 collected data on a group of 130 patients seen over a period of eight months in the offices of eight physicians in Auckland, New Zealand. A qualified nurse obtained from each patient a catheterized specimen of urine which was immediately refrigerated and within one hour was examined and cultured. The sttiking finding was "insignificant" bacteriuria ( < 10,000 organisms/ml) in 53 (41%) of the subjects. Even more important, however, was the observation chat 41 (32%) of these individuals had sterile urine cultures. In the patients without bacteriuria, the investigators termed the clinical entity "acute urethral syndrome." A comparison of the presenting symptoms in individuals with bacteriuria and those with acute urethral syndrome reveals no significant distinguishing characteristics (table 1). Loin pain, or costovertebral tenderness, occurred with comparable frequency in both groups. Significant pyuria ( > 5 WBC/hpf) was present in 10 (13%) of the 77 urine specimens from patients with bacteriuria as compared with 7 (13%) of 53 specimens from patients without bacteriuria. Subsequent studies have confirmed these observations. Gallagher and associates2 felt that many cases of acute urethral syndrome were due to infection confined to the urethra and surrounding glands. However, the etiology of the acute urethral syndrome, especially in chose patients who do not have pyuria, remains unknown. Studies in progress
POSTGRADUATE MEDICINE • September 1975 • Vol. 58 • No. 3
Downloaded by [Australian Catholic University] at 13:41 08 August 2017
Figure 1. Natural history of pyelonephritis illustrated hypothetically. From Jawetz E: Urinary tract infections. ln Aisner M, et al (Editors): Disease-A-Month, Nov 1954. © 1954 by Year Book Medical Publishers, lnc, Chicago. Used by permission.
have included searches for viral agents, chlamydiae (TRIC agents), gonococci, and bacterial spheroplasts. In patients with pyuria and other symptoms who have sterile cultures, it is essential to consider tuberculosis, fungal disease of the kidneys, and calculus disease. Although it remains to be proved, patients with the acute urethral syndrome who have pyuria are likely to benefit from antibacterial therapy, while those who do not have pyuria are not. Recognition of the acute urethral syndrome is important. Because this syndrome frequendy is not recognized, many women who do not have bacterial urinary tract infection are studied extensively, treated with cosdy and perhaps toxic antimicrobial agents, subjected to various invasive urologie procedures, and diagnosed as having "recurrent and chronic pyelonephritis." Since the classic work of Weiss and Parker,3 the occurrence of chronic renal disease as a consequence of pyelonephritis has been weil recognized. On the basis of numerous observations, it has been postulated that pyelonephritis might be a disease continuum rather than being a
Vol. 58 • No. 3 • September 1975 • POSTGRADUATE MEDICINE
Figure 2. Kinetic relationship of acute and chronic bacterial pyelonephritis to chronic renal disease.
169
Locating the Site of Infection
JAY P. SANFORD
Downloaded by [Australian Catholic University] at 13:41 08 August 2017
Dr. Sanford was formerly professor of internai medicine, University of Texas Southwestern Medical School at Dallas. He is now dean of the School of Medicine, Uniformed Services University of the Health Sciences, Bethesda.
TABLE 2. METHODS AVAILABLE FOR LOCALIZATION OF INFECTION IN THE URINARY TRACT
Direct
Indirect
Ureteral catheterization
Titration of serum antibodies
Renal biopsy
Urine concentration test
Bladder washout technique 7
Determination of urinary enzyme excretion Detection of a nti body-coated bacteria in urine
series of apparendy unrelated episodes4 (figure 1). The concept of a disease continuum reflects a retrospective approach which may be applicable co individual experiences. The problem may be becter recognized from the epidemiologie standpoint, as illustrated in figure 2. The anatomie changes designared as pyelonephritis can be produced by a number of noninfectious causes; these will not be considered in this discussion. There is general agreement thar both acute and chronic pyelonephritis can lead to the development of chronic renal disease; the unanswered question is, How frequendy does this progression occur? Definition of these relationships is paramount in quantifying the problem. As an initial approach, the assumption would seem justified thar infection limited to the lower urinary tract will not direcdy cause chronic renal disease, except as a potential source for ascending infection. The majority of patients seeking medical care for urinary tract infections do so because of dysuria. How frequendy do such patients have bacreriuria and, if bacteriuria is present, renal parenchymal involvement?
170
Reeves and Brumfitt11 stated that the understanding of urinary tract infection will advance considerably when a simple and reliable method is available for localization. The methods now available are summarized in table 2. Direct methods-The most reliable method for localization has been the recovery of bacteria in ureteral urine obtained from the affected kidney. Stamey and associates 6 have used the technique of urereral catheterization extensively to differentiate berween pyelonephritis and lower urinary tract infection. More recendy, Fairley and associates7 have developed an ingenious bladder washout technique for obtaining the equivalent of ureteral urine without the need to pass a ureteral catheter. The bladder washout procedure has been used quite extensively, and results correlate weil with those of ureteral cathererization. Unforrunately, the bladder washout procedure involves urethral carheterization and is too cumbersome for routine use. Indirect methods-While antibody citers and changes in the ability to produce a concentrated urine are useful indicarors in groups of patients, exceptions are sufficiendy frequent to make these determinations of less value when applied to an individual. Thomas and associates8 have described another indirect technique, which is based on the detection of antibody-coated bacteria in urine. Jones and associates9 have demonstrated that the presence of antibody-coated bacteria correlates very well with renal localization by the bladder washout technique in women; however, in men with prostatic infection, antibody-coated bacteria may be detecred in the absence of renal involvement.10 Review and Summary of Data
Knowledge of the natural history of a disease is essential co its rational diagnosis and management. Yet at this rime, data relevant to the natural history of symptomatic urinary tract infections are both scanty and conflicting. Review of these data emphasizes the necessity for a simple, reliable method of localization of infection. Fairley and associates 11 studied 66 women who were seen by general practitioners for symptoms of acute urinary tract infection. They did cultures and bladder washout localization studies in those with bacteriuria. From their observations (table 3), as well as from the studies cited previously, the clinical problem of urinary tract symptoms and infection in adules may be sumrned up as follows: Dysuria occurs in approximately 20% of women each year, half of whom seek medical
POSTGRADUATE MEDICINE
o
5eptember 1975
o
Vol. 58
o
No. 3
TABLE 3. DISTRIBUTION OF SYMPTOMS OF ACUTE URINARY TRACT INFECTION IN && PATIENTS SEEN IN GENERAL PRACTICE"
Manifestations
Percent with no bacteriuria or
![[Urinary tract infection].](/assets/img/hold.png)
