Clinical and laboratory features of urinary tract infections in young infants / Aspectos clínicos e laboratoriais da infecção do trato urinário em lactentes jovens

ABSTRACT Introduction: Urinary tract infection (UTI) is the most common serious bacterial infection in young infants. Signs and symptoms are often nonspecific. Objectives: To describe clinical, demographic and laboratory features of UTI in infants ≤ 3 months old. Methods: Cross-sectional study of infants ≤ 3 months old with UTI diagnosed in a pediatric emergency department, for the period 2010-2012. UTI was defined as ≥ 50,000 colony-forming units per milliliter of a single uropathogen isolated from bladder catheterization. Paired urinalysis and urine culture from group culture-positive and group culture-negative were used to determine the sensitivity and specificity of pyuria and nitrite tests in detecting UTI. Results: Of 519 urine cultures collected, UTI was diagnosed in 65 cases (prevalence: 12.5%); with male predominance (77%). The most common etiologies were Escherichia coli (56.9%), Klebsiella pneumoniae (18.5%) and Enterococcus faecalis (7.7%). Frequent clinical manifestations were fever (77.8%), irritability (41.4%) and vomiting (25.4%). The median temperature was 38.7°C. The sensitivity of the nitrite test was 30.8% (95%CI:19.9-43.4%), specificity of 100% (95%CI:99.2-100%). Pyuria ≥ 10,000/mL had a sensitivity of 87.7% (95%CI:77.2-94.5%), specificity of 74.9% (95%CI:70.6 -78.8%). The median peripheral white blood cell count was 13,150/mm3; C-reactive protein levels were normal in 30.5% of cases. Conclusions: The male: female ratio for urinary tract infection was 3.3:1. Non-Escherichia coli etiologies should be considered in empirical treatment. Fever was the main symptom. Positive nitrite is highly suggestive of UTI but has low sensitivity; whereas pyuria ≥ 10,000/mL revealed good sensitivity, but low specificity. Peripheral white blood cell count and C-reactive protein concentration have limited usefulness to suggest UTI.

RESUMO Introdução: A infecção do trato urinário (ITU) é um quadro infeccioso grave mais frequente em lactentes jovens, cujos sinais e sintomas são frequentemente inespecíficos. Objetivos: Descrever aspectos clínicos, demográficos e laboratoriais de ITU em lactentes ≤ 3 meses. Métodos: Estudo transversal de ITU diagnosticada em lactentes ≤ 3 meses, em pronto-socorro geral de pediatria, entre 01/01/2010 a 31/12/2012. Diagnóstico de ITU definida como crescimento ≥ 50.000 unidades formadoras de colônia por mililitro de uropatógeno único, colhido por cateterismo vesical. Urina tipo I e urocultura foram pareadas dos grupos cultura-positiva e cultura-negativa para determinar a sensibilidade e especificidade de piúria e teste do nitrito para o diagnóstico de ITU. Resultados: Das 519 uroculturas colhidas, confirmou-se 65 casos de ITU (prevalência: 12,5%), com predomínio em meninos (77%). As etiologias mais frequentes foram Escherichia coli (56,9%), Klebsiella pneumoniae (18,5%) e Enterococcus faecalis (7,7%). Os sintomas mais frequentes foram febre (77,8%), irritabilidade (41,4%) e vômitos (25,4%). A temperatura mediana foi de 38,7°C. A sensibilidade do nitrito positivo foi de 30,8% (IC95%:19,9-43,4%), especificidade de 100% (IC95%:99,2-100%). Piúria ≥ 10.000/mL apresentou sensibilidade de 87,7% (IC95%:77,2-94,5%), especificidade de 74,9% (IC95%:70,6-78,8%). A contagem mediana de leucócitos foi 13.150/mm3. A proteína C reativa foi normal em 30,5% dos casos. Conclusões: A proporção entre meninos e meninas para ITU foi de 3,3:1. Outros agentes além de Escherichia coli devem ser considerados no tratamento empírico. A febre foi a principal queixa. O nitrito positivo é altamente sugestivo de ITU mas tem baixa sensibilidade; enquanto que a piúria ≥ 10.000/mL revelou boa sensibilidade, porém baixa especificidade. Leucograma e proteína C reativa demonstraram pouca utilidade clínica para sugerir ITU.

Tratamiento antibiótico empírico de elección en pacientes con urosepsis secundaria a litiasis ureteral: reporte de sensibilidad local / Antimicrobial susceptibility of bacteria causing urosepsis

Background: Early inappropriate antibiotic therapy for the management of urosepsis is associated with higher mortality. Therefore, to establish an adequate empirical therapy is crucial. Aim: To determine an optimal antibiotic treatment, adjusted according local bacterial resistance in patients diagnosed with urosepsis secondary to ureteral lithiasis. Material and Methods: Urine cultures and blood cultures from a prospective cohort of patients with ureteral lithiasis admitted for urosepsis in our center between November 2013 and May 2016, were reviewed. Patients who presented two or more criteria of systemic inflammatory response syndrome (SIRS) and positive blood or urine cultures were admitted. Antimicrobial sensitivity patters derived from cultures were analyzed to describe bacterial susceptibility to commonly used antibiotics. Results: Data from 31 patients were analyzed. Seventeen blood cultures (55%) and 29 urine cultures (94%) were positive. The most commonly isolated pathogens were Escherichia coli in 65% of the cultures, followed by Klebsiella pneumoniae, Proteus mirabilis and Enterococcus faecalis. After performing an analysis of sensitivity and resistance for all bacteria in both blood and urine cultures, amikacin showed the highest sensitivity (100%), followed by 2nd and 3rd generation cephalosporins. Conclusions: Amikacin demonstrated higher antibiotic sensitivity in comparison to other antibiotics for empirical management of patients with urosepsis secondary to ureteral lithiasis.

Performance of the dipstick screening test as a predictor of negative urine culture / Desempenho da fita de urina como resultado presuntivo para cultura de urina negativa

ABSTRACT Objective To investigate whether the urine dipstick screening test can be used to predict urine culture results. Methods A retrospective study conducted between January and December 2014 based on data from 8,587 patients with a medical order for urine dipstick test, urine sediment analysis and urine culture. Sensitivity, specificity, positive and negative predictive values were determined and ROC curve analysis was performed. Results The percentage of positive cultures was 17.5%. Nitrite had 28% sensitivity and 99% specificity, with positive and negative predictive values of 89% and 87%, respectively. Leukocyte esterase had 79% sensitivity and 84% specificity, with positive and negative predictive values of 51% and 95%, respectively. The combination of positive nitrite or positive leukocyte esterase tests had 85% sensitivity and 84% specificity, with positive and negative predictive values of 53% and 96%, respectively. Positive urinary sediment (more than ten leukocytes per microliter) had 92% sensitivity and 71% specificity, with positive and negative predictive values of 40% and 98%, respectively. The combination of nitrite positive test and positive urinary sediment had 82% sensitivity and 99% specificity, with positive and negative predictive values of 91% and 98%, respectively. The combination of nitrite or leukocyte esterase positive tests and positive urinary sediment had the highest sensitivity (94%) and specificity (84%), with positive and negative predictive values of 58% and 99%, respectively. Based on ROC curve analysis, the best indicator of positive urine culture was the combination of positives leukocyte esterase or nitrite tests and positive urinary sediment, followed by positives leukocyte and nitrite tests, positive urinary sediment alone, positive leukocyte esterase test alone, positive nitrite test alone and finally association of positives nitrite and urinary sediment (AUC: 0.845, 0.844, 0.817, 0.814, 0.635 and 0.626, respectively). Conclusion A negative urine culture can be predicted by negative dipstick test results. Therefore, this test may be a reliable predictor of negative urine culture.

RESUMO Objetivo Verificar se a triagem de urina por fitas reativas é capaz de predizer a cultura de urina. Métodos Estudo retrospectivo realizado entre janeiro e dezembro de 2014 com 8.587 pacientes, com solicitação médica de triagem de urina (fita), sedimento urinário e cultura de urina. Foram analisados sensibilidade, especificidade, valor preditivo positivo, valor preditivo negativo e curva ROC. Resultados Foram positivas 17,5% das culturas. O nitrito apresentou sensibilidade de 28% e especificidade de 99%. O valor preditivo positivo foi de 89% e o valor preditivo negativo de 87%. Esterase apresentou sensibilidade de 79% e especificidade de 84%. Valor preditivo positivo e valor preditivo negativo foram de 51% e 95%, respectivamente. A combinação de nitrito ou esterase positivos apresentou sensibilidade de 85% e especificidade de 84%. Valor preditivo positivo e valor preditivo negativo foram, respectivamente, 53% e 96%. O sedimento positivo (mais de dez leucócitos por microlitro) apresentou sensibilidade de 92% e especificidade de 71%. O valor preditivo positivo foi 40% e o negativo, 98%. A combinação de nitrito e sedimento urinário positivos apresentou sensibilidade de 82% e especificidade de 99%. Os valores preditivos positivo e negativo foram 91% e 98%, respectivamente. Para o nitrito ou esterase positivos mais os leucócitos positivos, a sensibilidade foi de 94% e a especificidade de 84%. O valor preditivo positivo foi de 58% e o negativo foi de 99%. Com base na curva ROC, o melhor indicador de urocultura positiva foi a associação entre a esterase ou nitrito positivos na fita mais os leucócitos positivos no sedimento, seguido por nitrito e esterase positivos, sedimento urinário positivo isolado, esterase positiva isolada, nitrito positivo isolado e, finalmente, pela associação entre nitrito e sedimento urinário positivos (AUC: 0,845, 0,844, 0,817, 0,814, 0,635 e 0,626, respectivamente). Conclusão Uma urocultura negativa pode ser prevista com resultados negativos na fita. Portanto, este teste pode ser um preditor confiável de urocultura negativa.

Purple urine bag syndrome: case report for Streptoccocus agalactiae and literature review / Síndrome da urina roxa na bolsa coletora: relato de caso por Streptoccocus agalactiae e revisão da literatura

Abstract We report a case of purple urine bag syndrome, associated to Streptococcus agalactiae urinary tract infection, progressing to septic shock and death. We present a review of the literature on the subject and take the opportunity to attend readers about increasing incidence with population aging and its potential bad outcome.

Resumo Relatamos um caso de síndrome de urina roxa na bolsa coletora, associada à infecção do trato urinário por Streptococcus agalactiae, evoluindo para choque séptico e óbito. Apresentamos ainda uma revisão da literatura sobre o assunto e aproveitamos para atentar os leitores sobre o aumento de sua incidência com o envelhecimento populacional e seu potencial mau prognóstico.

Klebsiella pneumoniae ESBL formando esferoplastos em sedimento urinário a fresco sem coloração / Klebsiella pneumoniae ESBL forming spheroplasts in the fresh and unstained urine sediment

Resumo Um homem de 60 anos de idade foi submetido a transplante renal em 2013 devido à insuficiência renal crônica causada por hipertensão. Ele teve episódios recorrentes de infecção do trato urinário e veio para o hospital devido a 4 dias de febre, dor abdominal, ardência para urinar e náusea. Análise do sedimento urinário revelou um quadro de infecção (> 50 leucócitos/campo de grande aumento associado à bacteriúria maciça). O sedimento urinário revelou elementos alongados com um alargamento na parte central do corpo da estrutura.

Abstract A 60 year-old man was submitted to kidney transplantation in 2013 due to chronic renal insufficiency caused by hypertension. He had recurrent episodes of urinary tract infection and came to the hospital due to a 4 day-long fever, abdominal pain, burning urination and nausea. Routine urinalysis revealed a picture of infection (> 50 leucocytes/high power field associated to massive bacteriuria). The urine sediment revealed elongated like elements with an enlarged part in the middle of the structure body.

Síndrome de la bolsa de orina púrpura: un fenómeno inusual y muy llamativo / Purple urine bag syndrome: Report of one case

Purple urine bag syndrome is an uncommon but particularly striking phenomenon observed in people with urinary catheters and co-existent urinary tract infections. A chemical reaction between plastic and certain bacterial enzymes results in an intense purple urine color. We report a 72 year-old male with a cystostomy. A purple coloration of his urinary drainage bag and tubing was noted in the context of a urinary tract infection caused by Citrobacter freundii.

Prevalência de uropatógenos e sensibilidade antimicrobiana em uroculturas de gestantes do Sul do Brasil / Microbial etiology and susceptibility of community urinary tract infections during pregnancy in the south of Brazil

OBJETIVO: O objetivo do estudo foi avaliar a prevalência de germes e do perfil de sensibilidade a antimicrobianos a partir de uroculturas de pacientes gestantes atendidas em um hospital materno-infantil em Porto Alegre, Brasil. MÉTODOS : Foi realizado estudo transversal, retrospectivo e descritivo, no Hospital Fêmina, referência para atendimento às mulheres durante o pré-natal, parto e puerpério na cidade de Porto Alegre, Brasil. A partir de 1.558 uroculturas positivas, foram avaliados 482 resultados microbiológicos comunitários com perfil de sensibilidade antimicrobiana de uroculturas de gestantes em todas as idades gestacionais, atendidas no período de janeiro de 2007 a julho de 2013. RESULTADOS : O padrão de sensibilidade apresentado nesta pesquisa mostra que a escolha para o tratamento de infecção urinária durante a gravidez deve ser nitrofurantoína (para infecções não complicadas) ou cefalosporinas de segunda geração, como cefuroxima (para infecções não complicadas e complicadas), evitando o uso de ampicilina, cefalosporinas de primeira geração e sulfametoxazol/trimetoprim. CONCLUSÃO : O tratamento empírico de infecção urinária na gravidez deve ser iniciado de acordo com os padrões de suscetibilidade descritos na literatura, e revisto após os resultados de cultura de urina. .

PURPOSE : Urinary tract infection (UTI) is one of the most common conditions during pregnancy. The aim of this study was to assess the prevalence of germs and the antimicrobial susceptibility profile in urine culture isolates from pregnant patients treated at a tertiary maternity hospital in Porto Alegre, Brazil. METHODS : A cross-sectional, retrospective and descriptive study was carried out at Hospital Fêmina, a leading institution in prenatal, birth and postnatal healthcare in the city of Porto Alegre, Brazil. A total of 482 microbial community results were analyzed out of 1,558 positive urine cultures of pregnant women in all gestational ages treated at Fêmina Hospital between January 2007 and July 2013. RESULTS: The susceptibility pattern presented in this research shows that the choice for UTI treatment during pregnancy should be nitrofurantoin (for uncomplicated infections) or second-generation cephalosporins such as cefuroxime (for uncomplicated and complicated infections), over ampicillin, first-generation cephalosporins and sulfamethoxazole/trimethoprim. CONCLUSION : Empirical treatment for UTI in pregnancy should be started according to the susceptibility patterns described in the literature and re-analyzed after the results of the urine culture. .

Exame simples de urina no diagnóstico de infecção urinária em gestantes de alto risco / Urine test to diagnose urinary tract infection in highh-risk pregant women

OBJETIVO: Identificar a acurácia do exame simples de urina para diagnóstico de infecção urinária em gestantes de alto risco. MÉTODOS: Realizou-se um estudo transversal, prospectivo, em 164 gestantes admitidas na enfermaria de alto risco do Instituto de Medicina Integral Prof. Fernando Figueira (IMIP), no período de janeiro a junho de 2011. Foram excluídas as pacientes em uso de antibiótico nos últimos dez dias. Todas as pacientes foram submetidas aos exames de urina simples e urocultura no início de sua admissão. A concordância entre os resultados dos exames foi avaliada pelo índice Kappa (K), sendo, ainda, determinados a acurácia, sensibilidade, especificidade e valor preditivo positivo (VPP) e negativo (VPN). RESULTADOS: Utilizando como critério de diagnóstico apenas a presença de piócitos no exame simples de urina para sugerir bacteriúria, observou-se uma fraca concordância quando comparado à urocultura (K=0,16). A acurácia foi de 61%, com sensibilidade de 62,5% e especificidade de 60,6%. O VPP foi de 27,78% e o VPN, de 87%. CONCLUSÃO: Na presença de alteração do exame simples de urina não necessariamente está em curso uma infecção urinária, sendo necessária a realização da urocultura. Porém, quando o exame simples de urina for normal, a urocultura pode ser dispensada.

PURPOSE: To identify the accuracy of urinalysis in the diagnosis of urinary tract infection in pregnant women at high risk. METHODS: a prospective, cross-sectional study was conducted on 164 pregnant women admitted to the high-risk the ward of the Instituto de Medicina Integral Prof. Fernando Figueira (IMIP) during the period from January to June 2011. Patients who had been taking antibiotics in the last ten days were excluded. All patients were subjected to simple urine tests and urine culture at the beginning of their admission. The agreement between the results of the examinations was evaluated by Kappa indices (K), and accuracy, sensitivity, specificity, and positive (PPV) and negative (NPV) predictive values were also determined. RESULTS: When only the presence of pus cells in urinalysis was used as a diagnostic criterion suggesting bacteriuria, there was a poor agreement when compared to uroculture (K=0.16). Accuracy was 61%, sensitivity 62.5%, and specificity 60.6%. PPV was 27.78% and NPV was 87%. CONCLUSION: The presence of alteration of urinalysis does not necessarily indicate an ongoing urinary tract infection, with urine culture being necessary. However, when urinalysis data are normal, uroculture may be avoided.

Evaluación de sensibilidad antibiótica en urocultivos de pacientes en primer nivel de atención en salud de Pereira / Using an antibiotic sensitivity assay on urine cultures from patients attending general practice healthcare institutions in Pereira

Objetivos: Las Infecciones de vías urinarias son una causa de consulta muy frecuente en primer nivel de atención en salud. Describir los gérmenes más frecuentemente aislados y los patrones de resistencia a los antibióticos en urocultivos y antibiogramas de pacientes de primer nivel de atención de Pereira. Materiales y Métodos: Estudio descriptivo observacional de corte transversal, en una población de 131 608 afiliados al Sistema General de Seguridad Social en Salud entre el 1 de enero de 2010 y 7 de abril de 2011 evaluando las bacterias aisladas en urocultivos procesados con más de 100 000 Unidades Formadoras de Colonias y resultados de sensibilidad y resistencia de antibiogramas. La resistencia se evaluó bajo parametros de Clinical and Laboratory Standards Institute mediante método manual de difusión de disco Kirby-Bauer con sensidiscos Beckton Dickinson Diagnostics. Resultados: Se realizaron 5 226 urocultivos, de los cuales 1 058 mostraron crecimiento de uropatógenos. Un total de 792 (74,9 %) cultivos reportó el crecimiento de más de 105 UFC, Los microorganismos más frecuentemente aislados fueronEscherichia coli(67,2 %),Klebsiella sp(19,2 %) yEnterococcus sp(7,8 %).Escherichia colimostró sensibilidad alta para amoxicilina/clavulanato (100 %), nitrofurantoina (94,8 %), ceftriaxona (86,3 %), ciprofloxacina (71,0 %) y resistencia elevada para ampicilina (54,7 %), amoxicilina (50,0 %), trimetoprimsulfametoxazole (43,8 %) y cefalotina (42,8 %). Conclusiones: Nitrofurantoina puede ser la mejor opción terapéutica en primera línea de manejo en infecciones de vías urinarias bajas y ciprofloxacina para pielonefritis debido a su efectividad y poca resistencia en primer nivel de atención en Pereira.

Objectives: Describing the bacteria most frequently isolated from and antibiotic resistance patterns in urine cultures taken from patients attending general practice healthcare institutions in Pereira as urinary tract infections are a frequent cause for primary healthcare attention. Materials and Methods: A descriptive cross-sectional observational study of 131,608 members of the health social security system was carried out between January 1st 2010 and April 7th 2011;the bacteria isolated from urine cultures having more than 105 colony-forming units (CFU) were assessed, as were the sensitivity and antibacterial agents’ resistance results. Resistance was evaluated in line with Clinical and Laboratory Standards Institute (CLSI) parameters by means of the Kirby-Bauer disk diffusion manual method with Beckton Dickinson diagnostic disks. Results: 5,226 urine cultures were analysed, 1,058 of which showed uropathogengrowth. Bacterial growth was reported in 792 cultures (74.9 %), having more than 105 CFU. The most frequently isolated microorganisms were Escherichia coli (67.2 %), Klebsiella sp (19.2 %) and Enterococcus sp (7.8 %).Escherichia colishowed high sensitivity to amoxicillin / clavulanate (100 %), nitrofurantoin (94.8 %), ceftriaxone (86.3 %), ciprofloxacin (71.0 %) and high resistance to ampicillin (54.7 %), amoxicillin (50.0 %), trimethoprim-sulfamethoxazole (43.8 %) and cephalothin (42.8 %). Conclusions: Nitrofurantoin may be the best therapeutic option in first-line management of lower urinary tract infection and ciprofloxacin for pyelonephritis due to its effectiveness and low resistance as seen in primary healthcare practice in Pereira.

Análisis de resistencia en urocultivo 2005-2010 Hospital Roosevelt, ciudad de Guatemala / Analysis of urine culture resistance in 2005-2010 Roosevelt Hospital, Guatemala City

Objetivos: Determinar la frecuencia de microorganismos más comunes durante el período 2005-2010 en pacientes intrahospitalarios y ambulatorios y en las unidades de cuidados críticos con sospecha de infección urinaria, así como también establecer el padrón de resistencia acorde a los datos presentados...

Patrones de resistencia antimicrobiana en uropatógenos gramnegativos aislados de pacientes ambulatorios y hospitalizados Cartagena, 2005-2008 / Antimicrobial resistance pattern for gram-negative uropathogens isolated from hospitalised patients and outpatients in Cartagena, 2005-2008

Objetivo Determinar el patrón de resistencia antimicrobiana de bacterias patógenas asociadas a infecciones urinarias en pacientes ambulatorios y hospitalizados. Métodos Se realizó un estudio descriptivo entre febrero de 2005 y noviembre de 2008 en el Laboratorio Clínico de la Universidad de San Buenaventura, Cartagena. La susceptibilidad antimicrobiana fue evaluada con el método de difusión en agar empleado la técnica de Kirby Bauer aplicando procedimientos normalizados. Resultados Del total de muestras de orina analizadas (1 384) durante el período de estudio, 32,9 por ciento (455) fueron urocultivos positivos, la mayoría de éstos (81,4 por ciento) provenían de mujeres. Los agentes bacterianos más frecuentes fueron Escherichia. coli (60,1 por ciento), Klebsiella pneumoniae (6,9 por ciento), Pseudomonas aeruginosa (6,6 por ciento), Proteus mirabilis (5,4 por ciento) y Acinetobacter baumannii (1,4 por ciento). Los aislamientos gramnegativos mostraron una alta resistencia a la ampicilina (84,3100 por ciento), amoxacilina/ácido clavulánico (66,5 80,0 por ciento) y ciprofloxacina (40,057,9 por ciento). Conclusión Las bacterias gramnegativas fueron los principales agentes asociados a infecciones urinarias en esta población siendo E. coli el aislamiento más frecuente. La interpretación de los perfiles de susceptibilidad encontrados permite considerar como prudente la administración empírica de cefalosporinas de tercera generación como tratamiento inicial de las infecciones urinarias en esta población.

Objective Determining the microbial aetiology spectrum and antibiotic resistance pattern of uropathogens causing urinary tract infections in hospitalised patients and outpatients. Methods A descriptive study was carried out between February 2005 and November 2008 at the San Buenaventura University's Clinical Laboratory in Cartagena. Antibiotic sensitivity was determined by the Kirby Bauer method. Results Out of the total specimens (1,384) analysed over the four-year study period, 455 of the urine samples (32.9 percent) were culture positive, most (81.4 percent) having come from females. The bacterium isolated most frequently was Escherichia coli (60.1 percent) followed by Klebsiella pneumoniae (6.9 percent), Pseudomonas aeruginosa (6.6 percent), Proteus mirabilis (5.4 percent) and Acinetobacter baumannii (1.4 percent). The Gram-negative isolates displayed a high level of resistance to ampicillin (range 84.3100 percent), amoxicillin/clavulanic acid (range 66.580 percent) and ciprofloxacin (range 4057.9 percent). Conclusion Gram-negative bacteria were responsible for urinary tract infections in the patients involved in this study. The most commonly isolated bacteria were E. coli. Empirical administration of a third-generation cephalosporin for initial treatment of urinary tract infections in this population appears prudent from the perspective of antimicrobial susceptibility.

Infecciones del tracto urinario / Urinary tract infections

La infección del tracto urinario (ITU), con sus múltiples presentaciones clínicas, está entre las enfermedades infecciosas más frecuentes, tanto en pacientes ambulatorios como hospitalizados. El uso del examen de orina completa y de urocultivo debe ser racional. La bacteriuria asintomática no debe ser buscada ni tratada, en parte porque esto favorece el desarrollo de bacterias resistentes a antibióticos. Distintos cuadros clínicos requieren de distintas duraciones de terapia antibiótica, y tanto el exceso de días de tratamiento como su falta deben evitarse. Se requiere investigación en la búsqueda de estrategias más efectivas para prevenir las ITU recurrentes y en el desarrollo de nuevos antibióticos orales para las ITU resistentes.

Urinary tract infection, with its multiple clinical presentations, is one of the most common infectious diseases in both ambulatory and hospitalized patients. The urinalysis and urine culture should be used when appropriate. Asymptomatic bacteriuria should not be screened or treated, in part because of a concern for the selection of antibiotic resistant bacteria. The appropriate duration of treatment of urinary tract infection should be completed. Research is needed in newstrategies for prevention of recurrent urinary tract infections and development of new oral antibiotics for drug resistant bacteria.

Evaluation of urine collection methods for the diagnosis of urinary tract infection in children

To evaluate the accuracy of urine sample collection methods among children suspected of having urinary tract infections. Four methods for urine sample collection were evaluated in 1,067 children aged 0-16 years with suspected urinary tract infections over 2 months at Dr. Sami Ulus Children's Hospital. Within 30 min of collection, all specimens were sent to the laboratory, refrigerated and processed according to standard hospital microbiological procedures. Urine samples were analyzed using routine culture techniques. At initial sending of the urine culture, 617 [57.8%] had negative culture results, 145 [13.6%] had positive culture results, and 305 [28.6%] had evidence of bacterial contamination. Clean catch specimens showed a contamination rate of 14.3% and urethral catheterization specimens showed a similar contamination rate [14.3%]. However, urethral catheterization was preferred in only a small number of cases [n = 7]. Suprapubic aspiration was also used in a small number of cases [n: 11] and the contamination rate for suprapubic aspiration was 9.1% [n: 1/11]. The contamination rate for sterile urine bag was 43.9%, significantly higher than the other methods [p< 0.001]. Suprapubic aspiration showed the lowest contamination rate and sterile urine bag showed the highest contamination rate among 4 methods of urine sample collection. Contaminated specimens, needed to be repeated and this procedure increased the cost of urine culture. In conclusion, measures should be taken to reduce the contamination rate in our center. This is an area where further investigation is required

Accuracy of simple urine tests for diagnosis of urinary tract infections in low-risk pregnant women / La exactitud del examen de orina simple para diagnosticar infecciones del tracto urinario en gestantes de bajo riesgo / Acurácia do exame de urina simples para diagnóstico de infecções do trato urinário em gestantes de baixo risco

Anatomic and physiological alterations during pregnancy predispose pregnant women to urinary tract infections (UTI). This study aimed to identify the accuracy of the simple urine test for UTI diagnosis in low-risk pregnant women. Diagnostic test performance was conducted in Botucatu, SP, involving 230 pregnant women, between 2006 and 2008. Results showed 10 percent UTI prevalence. Sensitivity, specificity and accuracy of the simple urine test were 95.6 percent, 63.3 percent and 66.5 percent, respectively, in relation to UTI diagnoses. The analysis of positive (PPV) and negative (NPV) predictive values showed that, when a regular simple urine test was performed, the chance of UTI occurrence was small (NPV 99.2 percent). In view of an altered result for such a test, the possibility of UTI existence was small (PPV 22.4 percent). It was concluded that the accuracy of the simple urine test as a diagnostic means for UTI was low, and that performing a urine culture is essential for appropriate diagnosis.

Las alteraciones anatómicas y fisiológicas de la gravidez predisponen a las gestantes a infecciones del tracto urinario (ITU). El objetivo de este estudio fue identificar la exactitud del examen de orina simple para diagnosticar ITU en gestantes de bajo riesgo. Se hizo uso del estudio de desempeño de prueba de diagnóstico realizado en Botucatu, San Pablo, con 230 gestantes, entre 2006 y 2008. Los resultados muestran que la prevalencia de ITU fue de 10 por ciento. La sensibilidad fue 95,6 por ciento, la especificidad 63,3 por ciento y la exactitud 66,5 por ciento del examen de orina simple, en relación al diagnóstico de ITU. El análisis de los valores de predicción positivo y negativo (VPP y VPN) mostró que, en la vigencia de examen de orina simple normal, la probabilidad de haber ITU fue pequeña (VPN 99,2 por ciento). Frente al resultado alterado de ese examen, la probabilidad de haber ITU fue baja (VPP 22,4 por ciento). Se concluye que la exactitud del examen de orina simple como medio de diagnóstico de ITU fue baja, siendo indispensable la realización de urocultura para el diagnóstico.

Alterações anatômicas e fisiológicas da gravidez predispõem gestantes a infecções do trato urinário (ITU). O objetivo deste estudo foi identificar a acurácia do exame de urina simples para diagnóstico de ITU em gestantes de baixo risco. Fez-se uso do estudo de desempenho de teste diagnóstico realizado em Botucatu, SP, com 230 gestantes, entre 2006 e 2008. Os resultados mostram que a prevalência de ITU foi de 10 por cento. A sensibilidade foi 95,6 por cento, especificidade 63,3 por cento e acurácia 66,5 por cento do exame de urina simples, em relação ao diagnóstico de ITU. A análise dos valores preditivos positivo e negativo (VPP e VPN) mostrou que, na vigência de exame de urina simples normal, a chance de haver ITU foi pequena (VPN 99,2 por cento). Frente ao resultado alterado desse exame, a probabilidade de haver ITU foi baixa (VPP 22,4 por cento). Conclui-se que a acurácia do exame de urina simples como meio diagnóstico de ITU foi baixa, sendo indispensável a realização de urocultura para o diagnóstico.

Infecção do trato urinário na gravidez: aspectos diagnósticos, terapêuticos e prognósticos / Urinary tract infection in pregnancy: diagnostic, therapeutic and prognostic aspects

Infecção do trato urinário é complicação comum na gravidez devido às mudanças anatômicas e funcionais, sendo responsável por elevado número de complicações mateno-fetais. Em decorrência de sua importância, o presente trabalho faz atualização das recentes evidências quanto ao manejo dessa afecção. Ao final do primeiro trimestre, recomenda-se a triagem para bacteriúria asintomática em todas as gestantes. Mulheres com bacteriúria assintomática ou infecção urinária sintomática durante a gravidez devem ser tratadas e submeterem-se a screenings periódicos durante toda a gestação. Os beta-lactâmicos são os antibióticos de escolha para o tratamento dessas gestantes. Evidências sugerem uso de terapia oral por três a sete dias para cistite e parenteral de 14 dias para pielonefrite. As pacientes devem realizar urocultura de controle com 48 ou 72 horas de tratamento. A profilaxia é indicada em casos especívicos em dose única pós-coital ou diariamente com cefalexina ou nitrofurantoína. O presente artigo ainda discute a conduta em situações especiais, como em pacientes com litíase renal, traço falcêmico e ureterossigmoidostomia.

Urinary tract infection is a common complication of pregnancies due to functional, anatomic and hormonal changes. Given its importance, this current article reviews the current evidence on handling of this illness. At the end of the first trimester, a screening for asymptomatic bacteriuria is recommended for all pregnant women. The ones with asymptomatic bacteriuria or symptomatic UTI during childbearing should be treated and submitted to periodical screenings during all gestation period. The beta-lactams are the antibiotics chosen for the treatment of these pregnant women. Evidence suggests the use of 3 to 7 day oral therapy against cystitis and 14 day parenteral therapy against pielonefhritis. The patients should undergo urine culture within 48 or 72 hours of treatment. The single dose prophylaxis is indicated in specific cases after coitus or on a daily basis with the prescription of cephalexin or nitrofurantoin. This article still discusses the management in special situations, such as renal lithiasis, ureterossigmoidostomy and sickling trace.

Infección urinaria en niños: métodos de recolección de orina / Urinary tract infection in children: methods for collecting urine

La infección del tracto urinario (ITU) es una de las causas de infección más frecuente en la infancia. La ITU requiere confirmación microbiológica mediante urocultivo, por lo que la interpretación del mismo va a estar condicionada por la calidad de la recolección de la muestra de orina. Existen cuatro métodos de recolección de orina: Bolsa recolectora, cateterismo vesical, punción suprapúbica y micción espontánea con orina de 2° chorro. La elección de un método de recolección debería considerar los siguientes factores: edad del paciente, necesidad de inmediato diagnóstico y/o tratamiento antibiótico y planes futuros de estudios. Cada uno de los métodos presenta ventajas y desventajas respecto de sensibilidad, especificidad e invasividad. Después del análisis de cada una de estas condiciones para las diferentes formas de conseguir una muestra de orina, la conclusión de esta revisión es que debería usarse cateterismo vesical en todo niño menor de tres meses febril y en niños mayores febriles que no controlan esfínter y tienen un alto riesgo de ITU. Niños sin control de esfínteres y sin factores de riesgo podrían usar bolsa recolectora y, en caso de muestra positiva, deberían ser reevaluados por muestra de orina por sonda.

Urinary Tract Infection (UTI) is one of the most common causes of infection in childhood. This infection requires microbiological assessment by urine culture; therefore, an adequate sample collection method is critical to make an accurate diagnosis. There are four principal ways urine bag, vesical catheterism, spontaneous miction sample. The choice of one of these should consider patient's age, the need of a quick diagnosis, antimicrobial treatment and future studies. Each method has advantages and disadvantages about sensitivity, specificity and invasivity. After the analysis of these characteristics for each method, the conclusion in this review is that every febril patient younger than three months of age should be catheterized, as well as older children with high risk of UT/ and no sphincter control. For the rest of the patients, an urine bag could be used, and if positive for UTI, a catheterism should be performed.

Experiencia de educación continua basada en la notificación voluntaria de urocultivos y antibiogramas / Experience of continuous education through the voluntary notification of urine cultures and disk diffusion tests

Durante el desarrollo de diversos cursos de Bacteriología, tanto presenciales como a distancia, del Programa de Educación Continua (PROECO) de la Fundación Bioquímica Argentina, se solicitó a los colegas la notificación voluntaria de los resultados de los urocultivos y antibiogramas pertenecientes a pacientes ambulatorios, realizados entre el 1º de mayo y el 31 de julio de 2004 en los laboratorios en donde se desempeñaban. Del presente trabajo participaron ochenta y seis bioquímicos de treinta ciudades correspondientes a cuatro provincias argentinas. El objetivo general fue evaluar la importancia de las actividades de educación continua basadas en el análisis del trabajo cotidiano, a través de la notificación de los resultados de laboratorio de los urocultivos y antibiogramas, utilizando el papel didáctico del error como estrategia para aproximar la teoría y la práctica, con el objeto de implementar acciones que permitan normatizar los procedimientos de laboratorio y mejorar la calidad de los mismos. Con los resultados se confeccionó una base de datos en los programas de computación Excel 6.1 y SPSS 10.0 para procesarlos estadísticamente. De 1.260 datos, el 80% fueron aportados por los laboratorios privados y los restantes por los hospitales públicos y centros de atención primaria de salud municipales. El 80,6% de las muestras pertenecieron a mujeres y el 89% de los aislamientos correspondieron a bacilos gramnegativos. El agente más frecuente fue Escherichia coli 835 (66,3%); seguido por Proteus spp. 104 (8,3%); Klebsiella spp. 83 (6,6%); Staphylococcus spp. 79 (6,2%); Enterococcus spp. 43 (3,4%) y otros 116 (9,2%). Al analizar comparativamente las resistencias a antibióticos en los laboratorios privados y hospitalarios respecto de las publicadas por centros de referencia nacionales se encontraron similitudes y diferencias. Los errores de procedimiento detectados, tanto en la identificación de gérmenes como en los antibióticos ensayados, permitieron avanzar en la normatización de las técnicas. Desde el PROECO se dirigió una tarea de capacitación entre pares con supervisión docente, dentro de los talleres participativos nominales, enfatizando el valor del trabajo en el proceso de aprendizaje y favoreciendo la accesibilidad a los conocimientos. Esto también mostró la potencialidad del impacto indirecto de un programa de educación sobre actividades de vigilancia epidemiológica y la importancia que tiene la notificación de resultados de distintas patologías por parte de los laboratorios privados que aportaron cuatro veces más datos que el sector público, lo cual resulta interesante al momento de tomar medidas de prevención y la actualización de guías de tratamiento, incidiendo tanto sobre la prescripción médica como en la aún persistente venta directa de antibióticos en las farmacias. Esta publicación pretende ser un aporte preliminar para hacer notar la importancia de instalar una actividad de notificación de resultados con continuidad por parte del sector bioquímico privado y público, basada en el análisis de datos reales de la atención primaria de la salud, que contribuya a la toma de medidas sanitarias pertinentes en relación con diversas patologías.

During the development of diverse courses on Bacteriology such as in site classes or Distance learn-ing classes, of the Program of Continuous Education (PROECO) of the Fundación Bioquímica Argentina, colleagues were requested the voluntary notification of the results of urine cultures and disk diffusion tests from outpatients, carried out from May 1 to July 31, 2004 in the laboratories where they worked. Eighty-six biochemists from thirty cities from four Argentine provinces participated in this work. The general objective was to evaluate the importance of the activities of continuous education based on the analysis of daily work, through the notification of the laboratory results of urine cultures and disk diffusion tests using the didactic error as a strategy to approach theory to practice, in order to achieve actions that make it possible to standardize the laboratory procedures and to improve their quality. With the results a database was made using Excel 6.1 and SPSS 10.0 for statistical processing. A total of 1008 out of 1260 (80%) data were provided given by private laboratories and the 20% remaining by public hospitals and municipal centers of primary health attention. 80.6% of the samples belonged to women and in 89% of the cases gramnegative bacilli were isolated. The most frequent agent was Escherichia coli 835 out of 1260 (66.3%); followed by Proteus spp. 104 out of 1260 (8.3%); Klebsiella spp. 83 out of 1260 (6.6%); Staphylococcus spp. 79 out of 1260 (6.2%); Enterococcus spp. 43 out of 1260 (3.4%) and other 116 out of 1260 (9.2%). There were similarities and differences in the comparison of the resistances to antibiotics in private and public hospital laboratories with those published by the national reference center. The procedure errors detected both in the identification of germs and in the rehearsed antibiotics enabled the improvement of the standardization of the techniques. PROECO ran a training task among colleagues with educational supervision, inside the nominal participatory workshops, emphasizing the value of work in the learning process improving the accessibility to knowledge. This also showed the potentiality of the indirect impact of an educational program about epidemic surveillance, and the importance of the notification of results of different diseases from private laboratories, which contributed with four times more data than the public sector, which is interesting at the moment of taking prevention and treatment measures, impacting both on the medical prescription and on the dispensation of antibiotics by pharmacists. This article tries to be a preliminary contribution to highlight the importance of achieving an activity of notification of the results with continuity by the private biochemical sector that contributes to take pertinent sanitary measures in relation to different diseases.

Comparación de la observación de leucocitos en el sedimento urinario con el recuento en cámara de Neubauer / Comparison between the observation of white blood cells from centrifuged urine smear and the Neubauer chamber

Se comparó la metodología rutinaria de observación del sedimento urinario entre porta y cubreobjetos con el recuento en cámara de Neubauer, tomado como método de referencia y se verificó su capacidad de predicción de bacteriuria significativa. En un período de dos meses se realizaron 2.287 urocultivos. Sólo 1.153 resultaron evaluables según los criterios de exclusión y en 982 se pudo correlacionar ambos métodos microscópicos con el resultado de los cultivos. La correlación entre los recuentos en cámara y las observaciones del sedimento urinario fue del 96,4%. Las sensibilidades respectivas de la observación del sedimento y del recuento en cámara respecto del urocultivo fueron de 53,5% y 55,5%. Las especificidades respectivas fueron del 90,7% y 91,4%. A partir de los resultados obtenidos se infiere que la observación de leucocituria significativa es predictiva de la bacteriuria significativa. Por el contrario, su ausencia no puede ser un motivo para descartarla. La observación del sedimento entre porta y cubreobjetos resultó prácticamente equivalente al método más tedioso de recuento en cámara de Neubauer.

The current method of centrifuged urine smear was compared to the Neubauer chamber method, using this technique as the gold standard. Their predictive ability for detecting significant bacteriuria was determined. During two months, 2.287 urine cultures were studied. Only 1.153 were evaluable. In 982 samples a comparison between the two microscopic methods could be established. The correlation between them was 96,4%. The sensitivity of the centrifuged urine smear and the Neubauer chamber method was 53.5% and 55.5% respectively. Specificities were 90.7% and 91.4%. Those results pointed out that seeing a significant number of polymorphonuclear neutrophils (PMNs) both in the centrifuged urine smear and in the Neubauer chamber was predictive of significant bacteriuria. On the other hand, absence of PMNs is not an argument for not considering this possibility. Centrifuged urine was equivalent to the Neubauer chamber method in this comparative study.

Patrones de resistencia bacteriana en urocultivos en un hospital oncológico / Antimicrobial resistance patterns of isolates from urine cultures at an oncological center

OBJETIVOS: Describir los patrones de resistencia bacteriana en cultivos de orina en un hospital oncológico. MATERIAL Y MÉTODOS: Se incluyeron las cepas obtenidas de cultivos de orina de 1998 a 2005. Se obtuvo el porcentaje de sensibilidad para diferentes antibióticos, tras analizar por separado cepas nosocomiales y compararlas con las de la comunidad. RESULTADOS: Se detectaron 9 232 cultivos positivos (20.7 por ciento) de 44 447 muestras: gramnegativos, 78.8 por ciento; grampositivos, 13.8 por ciento; y levaduras, 7.4 por ciento. Escherichia coli fue el principal microorganismo identificado (41.3 por ciento); la resistencia en aislados nosocomiales fue mayor que en la comunidad para amikacina (92.4 y 97 por ciento), ceftazidima (83.1 y 95.1 por ciento) y ciprofloxacina (46.2 y 58.6 por ciento). De igual manera, Pseudomonas aeruginosa presentó mayor resistencia para amikacina y ceftazidima en las cepas nosocomiales (55.7 y 66.6 por ciento; y 65.5 y 84.8 por ciento, respectivamente). Enterococcus resistente a vancomicina se encontró sólo en 2.5 por ciento (3/119 aislados de E. faecium). CONCLUSIONES: Existe una mayor resistencia bacteriana en las cepas de origen nosocomial en comparación con las cepas comunitarias. Se encontró un incremento progresivo de la resistencia para E. coli, el patógeno aislado con más frecuencia de infecciones nosocomiales y comunitarias. Es prioritario intensificar una campaña educativa para el control y uso racional de los antibióticos.

OBJECTIVE: To describe the patterns of antimicrobial resistance of organisms isolated from urine cultures at a teaching oncological hospital for adult patients. MATERIAL AND METHODS: All strains obtained from urine cultures from 1998 to 2005 were included. Mean susceptibilities were obtained for each antimicrobial tested; nosocomial and community-acquired isolates were analyzed separately. RESULTS: A total of 9 232 positive urine cultures were obtained (20.7 percent) from 44 447 samples taken. Gram negative bacteria were reported in 78.8 percent, Gram-positive in 13.8 percent and yeasts in 7.4 percent. Escherichia coli was the most frequently isolated bacterium (41.3 percent); antimicrobial resistance was higher in nosocomial isolates than in community strains (amikacin 92.4 vs. 97 percent, ceftazidime 83.1 vs. 95.1 percent and ciprofloxacin 46.2 vs. 58.6 percent). Pseudomonas aeruginosa showed a greater resistance to amikacin and ceftazidime in nosocomial cultures compared to community-acquired bacterial cultures (55.7 vs. 66.6 percent and 65.5 vs. 84.8 percent respectively). Vancomycin-resistant enterococci were found in only 2.5 percent (3 of 119 E. faecium isolates). CONCLUSIONS: Higher bacterial resistance was observed in nosocomial cultures than in community ones. Antimicrobial resistance was found to be progressively increasing for E. coli, the most frequent pathogen isolated both in nosocomial and community infections. We consider imperative the establishment of an intense educational campaign for the use and control of antibiotics.

Incremento de los urocultivos positivos en un hospital de cuarto nivel de atención / Increment in positive urine cultures in a fourth level attention hospital

Objetivo. Determinar si la implementación de intervenciones educativas y administrativas con respecto al empleo de pruebas de tamizaje incrementa la proporción de urocultivos positivos, en comparación con no emplear dichas intervenciones. Diseño. Este es un estudio prospectivo, analítico. Lugar. Hospital Pablo Tobón Uribe, Medellín, Colombia. Población. Se realizaron 25.766 urocultivos entre 1998 y 2005. Métodos. Algunas acciones educativas y administrativas se realizaron para incrementar la positividad de los urocultivos solicitados.Se registraron las coloraciones de Gram ordenadas para las muestras de los pacientes hospitalizados y atendidos en urgencias que fueron hospitalizados, los urocultivospositivos de los recomendados, los solicitados directamente por el médico tratante y por el servicio solicitante. Resultados. El porcentaje de coloraciones de Gram de orina sin centrifugar realizadas por urocultivo, en los pacientes hospitalizados, se incrementó de 0,7 por ciento en 1998 a 32,1 por ciento en 2005 ( p = 0,000). Los urocultivos fueron positivos en el 79,4 por ciento de los casos cuando se realizaron por recomendación del laboratorio, mientras que la positividad de los solicitados directamente fue del 27,9 por ciento (p = 0,000). El porcentaje total de urocultivos positivos en 1998 en los pacientes que fueron hospitalizados, fue de 29,7 por ciento, mientras que de 1999 a 2005 fue del 40,3 por ciento, años en los cuales el laboratorio de microbiología intervino activamente (c2 = 74,95; p = 0,000). Los urocultivos positivos solicitados desde urgencias de adultos y pediatría aumentaron de 34 por ciento y 15 por ciento en 1998, a 66 por ciento y 30 por ciento en el 2005, respectivamente; mientras que en otros servicios de hospitalización el porcentaje pasó de 26 por ciento a 40 por ciento. Conclusiones. El porcentaje de los urocultivos positivos se puede incrementar si el conocimiento derivado del estudio de las pruebas de tamizaje es aplicado a la práctica clínica

AbstractGoal:To determine if the implementation of educativeand administrative interventions with respect to theuse of screening tests increases the proportion ofpositive urocultures, in comparison with the absenceof using these interventions. Design:The study is aprospective, analytical study. Place: Hospital Pablo To-bón Uribe, Medellín, Colombia. Population: 25.766urocultures obtained from 1998 to 2005. Methods:some educative and administrative actions were takento increase the positivity of the requestes urocultures.All data from ordered urocultures were registered.The ordered Gram stains in hospitalized patients andpatients who attended the emergency unit that werehospitalized, the positive urocultures of the recom-mended ones, those requested directly by the medicalpractitioners, and services. Results: Gram stainpercentage without centrifugation for uroculture inhospitalized patients increased from 0.7% in 1998 to32.1% in 2005 (p = 0.000). Urocultures were positivein 79.4% of the cases when they were done bylaboratory recommendation, whereas positivity ofdirectly requested cultures was of 27.9% (p = 0.000).The total percentage of positive urocultures in 1998for hospitalized patients was 29.7%, and in 1999-2005was 40.3% (c2 = 74.95;p = 0.000), period when themicrobiology laboratory intervened actively. Positiveurocultures from requested for adult and pediatricemergency patients increased from 34% and 15% in1998 to 66% and 30% in 2005, respectively; in otherhospitalization services the percentage increased from26% to 40%. Conclusions:The percentage ofpositive urocultures may increase if the knowledgederived from the study of the corresponding screeningtests is applied to the clinical practice