The clinical rate of antibiotic change following empiric treatment for suspected urinary tract infections.

PURPOSE: To determine the rate of antibiotic change in an outpatient setting following empiric treatment of culture proven UTI and to identify risk factors associated with change. METHODS: Patients with suspected UTI and urine culture were reviewed (January 2016-June 2016). Those with a positive culture were categorized by whether or not they were treated empirically. Empiric treatment was evaluated for associations with clinical-demographic data, symptoms and urinalysis (UA). Antibiotic change was evaluated with clinical-demographic data, urine culture, and resistance patterns. RESULTS: 916 urine cultures (636 patients) were included. 391 (43%) cultures were positive, and 164 (42%) were treated empirically. Clinical-demographic data did not differ between groups. Those treated empirically had more documented UTI symptoms (93 vs 58%, P < 0.001), and UA abnormalities including positive nitrites (51 vs 29%, P < 0.001), 3 + leukocyte esterase (27 vs 19%, P = 0.002) and 3 + blood (13 vs 4%, P = 0.005). Of those treated empirically, 42/164 (26%) required an antibiotic change, and this was associated with immunosuppression (12 vs 2%, P = 0.027) resistance to > 3 antibiotics (33 vs 20%, P = 0.039) and also resistance to fluoroquinolone (50 vs 30%, P = 0.016), monobactam (19 vs 7% P = 0.042) and TMP-SMX (52 vs 19%, P < 0.001). CONCLUSIONS: Almost one-quarter of patients treated empirically required antibiotic change. This was driven largely by bacterial resistance. New technologies allowing rapid bacterial identification and sensitivity may improve patient care.

An Update on Fluoroquinolones: The Emergence of a Multisystem Toxicity Syndrome.

INTRODUCTION: The FDA (U.S. Food and Drug Administration) recently revised the boxed warning on fluoroquinolones to address serious safety concerns. This action was prompted by a growing number of reports involving patients with a constellation of symptoms now called fluoroquinolone associated disability. METHODS: Internet and literature searches were performed to identify previous reports of quinolone induced multisystem toxicity syndromes. The 3 terms fluoroquinolone toxicity, quinolone toxicity syndrome and fluoroquinolone associated disability were used to query PubMed® and Google's search engine for available information. RESULTS: Four primary sources emerged, including a recent FDA review, 2 case series and robust social media platforms. The FDA identified 1,122 fluoroquinolone disability reports from November 1, 1997 to May 30, 2015. A total of 178 cases qualified as fluoroquinolone associated disability after applying inclusion and exclusion criteria. Some estimate that there are as many as 45,000 cases of fluoroquinolone toxicity syndrome in the United States. All sources agree the affected population is generally young (mean age 40s to 50s), previously healthy and predominantly female. The FDA analysis revealed that average symptom duration was 14 months and longest duration was 9 years at the time of the review. CONCLUSIONS: Fluoroquinolone toxicity syndromes do not affect the majority of exposed patients but are likely underappreciated. As providers seeking to heal and avoid harm to our patients, diligent prescribing practices are paramount, as are early recognition and discontinuation of the antibiotic.

Dorsal Lumbotomy Incision for Partial Nephrectomy in Patients With Small Posterior Renal Masses.

OBJECTIVE: To describe our single-surgeon experience with dorsal lumbotomy, an uncommonly utilized muscle-sparing incision, for open partial nephrectomy. MATERIALS AND METHODS: We retrospectively identified patients who underwent partial nephrectomy through dorsal lumbotomy incision by a single surgeon from September 2012 through April 2014. Clinicopathologic characteristics were recorded along with early postoperative outcomes including hospital length of stay and narcotic requirement. RESULTS: Twenty-four patients were identified for analysis. Median operative time was 71 minutes (interquartile range [IQR]: 63-91 minutes), and median estimated blood loss was 250 mL (IQR: 100-438 mL). Median length of stay was 1.2 days (IQR: 0.94-2.0 days) and median narcotic requirement was 17 mg of oral morphine equivalents (IQR: 4.9-43 mg). Overall perioperative complication rate was 25% including 1 major (Clavien III-V) complication. CONCLUSION: Partial nephrectomy via dorsal lumbotomy incision is a safe and feasible option for small posterior renal masses when performed by an experienced surgeon. The drawbacks of this approach are limited access to the renal hilum and risk of injury to the iliohypogastric or subcostal nerves. Dorsal lumbotomy is associated with postoperative outcomes equivalent to or better than standard operative approaches and should be considered a viable surgical approach in selected cases.

Using the Native Afferent Nervous System to Sense Bladder Fullness: State of the Art.

The regulation of micturition involves complex neurophysiologic pathways, and its understanding has grown immensely over the past decade. Alternative approaches and applied technologies in the treatment of bladder dysfunction have minimized the complications that result from neurogenic bladder. The use of natural bladder mechanoreceptors and electroneneurographic (ENG) signal recordings from afferent nerves to chronically monitor bladder volume is a promising concept, but the technology to accomplish this has proven to be a great biomedical engineering challenge. The focus of this paper will be to describe the current state of ENG signal recording as a method to detect bladder fullness.

Large Bladder Clot-An Unusual Presentation of Neonatal Bilateral Renal Vein Thrombosis-Case Report and Review of Literature.

A 1-day-old boy born at 37 weeks gestation presented with hematuria, thrombocytopenia, and palpable irregular right flank mass. Renal ultrasound demonstrated large clot within the bladder, bilateral kidney masses with loss of corticomedullary differentiation, and reversal of diastolic flow. The patient was diagnosed with bilateral renal vein thrombosis and was managed conservatively. There was complete resolution of the bladder clot with restoration of corticomedullary differentiation bilaterally. We report the first case of renal vein thrombosis associated with a large bladder clot in a neonate.