Short-term effectiveness of ceftriaxone single dose in the initial treatment of acute uncomplicated pyelonephritis in women. A randomised controlled trial.
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OBJECTIVE: To compare the short-term effectiveness of ceftriaxone single dose followed by cefixime with a standard treatment of acute uncomplicated pyelonephritis in women. METHODS: An open, prospective, and randomised trial of women with acute uncomplicated pyelonephritis was performed. Group A were given a daily intravenous dose of 1 g ceftriaxone; group B: ceftriaxone 1 g intravenous single dose followed by oral cefixime. When urine culture was received, both groups completed a 10 day treatment based in sensitivity studies. Only women with positive initial urine culture were included. After three days of treatment, clinical and bacteriological efficacy was assessed. Clinical response was classified as "cured" if acute symptoms (fever, urinary syndrome and flank pain) were settled. Bacteriological response was classified as: eradication, or no eradication. RESULTS: Of 144 eligible patients, urine culture was positive in 54 of 72 (75%) women in group A and 51 of 72 (71%) in group B. There were no significant differences between groups in resolution of acute symptoms. Clinical cure was observed in 49 of 54 (91%) patients in the group A and in 47 of 51 (92%) patients in the group B (p = 0.68). After three days of treatment urine culture was negative for all patients. No adverse effects were observed in either of the groups. CONCLUSION: These data suggest that a intravenous single dose of ceftriaxone followed by oral cefixime is both effective and safe for the initial treatment of acute uncomplicated pyelonephritis in women. This regimen could be useful in managing selected patients with pyelonephritis as outpatients. (+info)
Unpredicted spontaneous extrusion of a renal calculus in an adult male with spina bifida and paraplegia: report of a misdiagnosis. Measures to be taken to reduce urological errors in spinal cord injury patients.
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BACKGROUND: A delay in diagnosis or a misdiagnosis may occur in patients with spinal cord injury (SCI) or spinal bifida as typical symptoms of a clinical condition may be absent because of their neurological impairment. CASE PRESENTATION: A 29-year old male, who was born with spina bifida and hydrocephalus, became unwell and developed a swelling and large red mark in his left loin eighteen months ago. Pyonephrosis or perinephric abscess was suspected. X-ray of the abdomen showed left-sided staghorn calculus. Since ultrasound scan showed no features of pyonephrosis or perinephric abscess, he was prescribed a prolonged course of antibiotics for infection presumed to arise from the site of metal implant in spine. He developed a discharging sinus, following which the loin swelling and red mark subsided. About three months ago, he again developed a red mark and minimal swelling in the left loin. Ultrasound scan detected no abnormality in the renal or perinephric region. Therefore, the red mark and swelling were attributed to pressure from the backrest of his chair. Five weeks later, the swelling in the left loin burst open and a large stone was extruded spontaneously. An X-ray of the abdomen showed that he had extruded the central portion of the staghorn calculus from left kidney. With hindsight, the extruded renal calculus could be seen lying in the subcutaneous tissue of left loin lateral to the 10th rib in the X-ray of abdomen, which was taken when he presented with red mark and minimal swelling. CONCLUSION: This case illustrates how mistakes in diagnosis could occur in spinal cord injury patients, and highlights the need for corrective measures to reduce urological errors in these patients. Voluntary reporting of urological errors is recommended to facilitate learning from our mistakes. In the patients who have marked spinal curvature, ultrasonography of kidneys and perinephric region may not be entirely reliable. As clinical symptoms and signs may be non-specific in SCI patients, they require prompt, detailed and occasionally, repeated investigations. A joint team approach by health professionals belonging to various medical disciplines, which is strengthened by frequent, informal and honest discussions of a patient's clinical condition, is likely to reduce urological errors in SCI patients. (+info)
Color and power Doppler sonography versus DMSA scintigraphy in acute pyelonephritis and in prediction of renal scarring.
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Capabilities of color and power Doppler sonography (DS) were prospectively evaluated for diagnosis of acute pyelonephritis and for prediction of scarring by comparison with 99mTc-dimercaptosuccinic acid scintigraphy (DMSA). METHODS: Fifty-seven children (mean age, 5 +/- 3 y) with acute pyelonephritis were investigated by biologic testing, DS (DS 1), and DMSA (DMSA 1). Patients who were <6 mo old or had high-grade reflux or obstruction were excluded. Forty-five children had a clinical follow-up examination, biologic testing, DS (DS 2), and DMSA (DMSA 2) at a mean of 7 +/- 2 mo after acute infection. Sonography (gray-scale and DS) was performed by 1 experienced radiologist who was unaware of patient data. DMSA studies were interpreted by 2 physicians who were unaware of patient data. RESULTS: Temperature, neutrophil count, and C-reactive protein value were significantly higher in patients with abnormal DMSA 1 findings than in those with abnormal DS 1 findings (P < 0.05). When compared with DMSA 1, DS 1 had a sensitivity and specificity of 80% and 81%, respectively. At follow-up, all clinical and biologic data had normalized. Scarring after infection occurred in 51% of children. When compared with DMSA 2, DS 1 had positive and negative predictive values of 57% and 75%, respectively, and DMSA 1 had respective values of 62% and 100%. Reflux was not considered a good predictor of scarring. CONCLUSION: DS and DMSA results were concordant in 81% of kidneys with acute pyelonephritis. The predictive value of DS for renal scarring was not considered sufficiently high for DS to be used in routine practice. (+info)
Pyelonephritis caused by multiple clones of Escherichia coli, susceptible and resistant to co-amoxiclav, after a 45 day course of co-amoxiclav.
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OBJECTIVES: We studied the clonal relatedness, in terms of phylogenetic group, virulence factors and co-amoxiclav resistance, of different Escherichia coli isolates obtained from blood and urine of a patient who had taken a 45 day course of co-amoxiclav. PATIENTS AND METHODS: The isolates were typed by molecular methods, and the virulence and resistance genes studied by PCR. RESULTS: The four phenotypically different E. coli isolates were classified into four clones and two phylogenetic groups (B2 and A), and displayed different virulence gene patterns. The two isolates resistant to co-amoxiclav were phylogenetically and clonally different, and harboured two different bla(TEM) genes. CONCLUSION: These two bla(TEM) genes did not derive from each other following a mutant selection process in vivo. (+info)
Plasma and urinary soluble adhesion molecule expression is increased during first documented acute pyelonephritis.
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BACKGROUND: The degree of inflammatory reaction and leucocyte trafficking during acute pyelonephritis has been related to the risk of developing renal parenchymal scarring. Adhesion molecules play a central role in leucocyte recruitment during inflammation. AIMS: (1) To determine whether circulating and urinary concentrations of E-selectin and intercellular adhesion molecule 1 (ICAM-1) were abnormal during first documented acute pyelonephritis; (2) to investigate whether circulating or urinary concentrations were predictive for the development of abnormalities on DMSA imaging. METHODS: Plasma and urine samples were collected from 40 children with a first episode of acute pyelonephritis within one week of infection (acute sample) and at six weeks (late sample). Control samples were collected from 21 healthy age matched controls and 18 age matched controls with febrile illness not secondary to urinary tract infection. RESULTS: Plasma and urinary sE-selectin were higher in acute samples (median 176.3 ng/ml and 0.12 ng/mmol respectively) compared with late (97.8 ng/ml and 0.029 ng/mmol) and both control (65.6 ng/ml and 0 ng/mmol) and febrile control (urine 0 ng/mmol) samples. Plasma sICAM-1 was higher in acute samples (428 ng/ml) than controls (365.2 ng/ml), and acute sICAM-1 urine concentrations were higher than febrile control concentrations (3.2 v 0.7 ng/mmol). No correlations were detected between sE-selectin or sICAM-1 and acute or late DMSA scan changes. CONCLUSION: Plasma and urinary sE-selectin and sICAM-1 are significantly increased during acute pyelonephritis, though no correlation exists between the presence of high plasma or urine concentrations and DMSA scan changes, both during acute infection and six weeks post-infection. (+info)
Impaired whole-blood polymorphonuclear leukocyte migration as a possible predictive marker for infections in preterm premature rupture of membranes.
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OBJECTIVES: Steroids, used in preterm premature rupture of membranes (pPROM), to reduce the risk of morbidity and mortality of the preterm neonate, impair the maternal polymorphonuclear leukocyte (PMN)-based immune system. In spite of combination with antibiotics, prenatal and postnatal bacterial infections of mother and child are frequent. This pilot study focuses on the influence of steroids in pPROM on maternal PMN functional capacity and subsequent infections. METHODS: After opting for expectant management, eight women with pPROM and no signs of infection were treated by steroids (betamethasone 5.7 mg, i.m. every 24 hours, for three days) and antibiotic therapy with either amoxicillin and clavulanic acid, piperacillin or ampicillin i.v. up to delivery. The conventional inflammation parameters of PMN blood count and C-reactive protein (CRP) were measured daily in parallel with PMN migratory capacity towards N-formyl-methionyl-leucyl-phenylalanine stimulation and under blank conditions, estimated by a whole blood membrane filter assay. RESULTS: In all patients PMN migration decreased during the application of steroids. Three patients showed a decrease in PMN migration below critical values and in spite of antibiotic prophylaxis acute pyelonephritis developed 2-6 days later. PMN count and CRP were not predictive of maternal infection. CONCLUSION: Reduced PMN function, caused by steroid treatment in pPROM, is suggested to be a reason for serious bacterial infections in spite of antibiotic prophylaxis. PMN migration reflects individual PMN defensive capacity. (+info)
Acute graft pyelonephritis and long-term kidney allograft outcome.
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BACKGROUND: Long-term graft function is the result of multiple parameters, including both immune and non-immune components, which have a beneficial or detrimental potential. Among these, despite its frequency and theoretical interest (expression of "danger signals" in the graft itself), the effects of acute graft pyelonephritis (AGPN) on immediate and long-term outcome have not been studied in a large series. This article reviews a cohort of 1387 consecutive primary renal transplant recipients. METHODS: The objective of the study was to define the risk factor for AGPN, the risk profile for recurrence, and the impact of AGPN on long-term graft survival. According to a higher risk for AGPN in females during their follow-up, statistical analyses (Cox model, and multiple regression analysis) were performed by recipient sex strata. RESULTS: Multivariate analysis showed that CMV infection was the only risk factor for AGPN occurrence. AGPN occurred in 13% of the graft recipients during their follow-up. Taken as a whole, AGPN was not associated with a significantly poor long-term outcome. However, when assessed in more detail, the outcome of this population was found to be more complex and to depend on several factors. Early AGPN (during the first 3 months) was significantly detrimental for graft outcome, independently of acute rejection episodes. Moreover, E. coli involvement in a first episode was linked to an increased AGPN recurrence. CONCLUSION: This analysis did not support the concept that with current immunosuppression, strong "danger signals" such as those derived from bacteria within an allograft, are instrumental in initiating acute or chronic rejection. (+info)
Molecular epidemiology of 3 putative virulence genes for Escherichia coli urinary tract infection-usp, iha, and iroN(E. coli).
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This study describes the epidemiological association of 3 putative genes for virulence of uropathogenic Escherichia coli; uropathogenic specific protein (usp), a Vibrio cholerae zot gene homologue; IrgA homologue adhesin (iha), a nonhemagglutinating adhesin; and iroN(E. coli), a catechole siderophore receptor homologue. We compared the relative frequency in urinary tract infection (UTI) isolates (n=508), compared with non-UTI isolates (n=416). iroN(E. coli) occurred 2.1-3.6 times more frequently in UTI isolates than in rectal isolates (P=1.1x10-18 to P=2.7x10-5) and was associated with several uropathogenic virulence genes found on pathogenicity islands. usp occurred more frequently in isolates from patients with pyelonephritis (P=3.6x10-9), in periurethral isolates (P=.001), and in isolates from patients with UTI who were aged 40-65 years (P=.004), when compared with the rectal isolates; iha was not associated with UTI in this study. (+info)