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PubMed1983

Does low urinary sIgA predispose to urinary tract infection?

Median urinary secretory IgA (sIgA) (ELISA technique in unprocessed urine) was 1.36 mg/liter (range, 0.29 to 2.31) in healthy female controls at various times of the menstrual cycle. It was significantly lower in women with urinary tract infection (UTI) without antibody-coated bacteria. Such decrease was found both in women with acute UTI episodes (median, 0.16; range, 0.06 to 1.71) and in asymptomatic nonbacteriuric women with a history of UTI (median, 0.52; range, 0.05 to 2.13). In the latter women, sIgA in nasal secretions tended to be low, but salivary sIgA was unchanged. Urinary sIgA was elevated significantly in individuals with nephrostomy and antibody-coated bacteria (14.4 mg/liter, range, 3.6 to 20). The study showed that locally synthesized sIgA immunoglobulins were low in the urine of individuals with recurrent UTI independent of the presence or absence of bacteriuria at the time of the study. UTI per se did not interfere with sIgA secretion as shown by high sIgA in patients with upper UTI. Low urinary sIgA may represent one factor predisposing to recurrent UTI.

Adolescent↗
PubMed1991

N-acetyl-beta-D-glucosaminidase in the localisation of urinary tract infection in patients with spinal cord injury.

This study evaluates the pattern of urinary N-acetyl-beta-D-glucosaminidase (NAG) isoenzyme excretion in patients with spinal cord injury (SCI) and its use as a diagnostic tool in localising the site of urinary tract infection (UTI). NAG-B excretion in 27 control SCI patients (mean 207.78 units) was significantly higher than in 10 normal controls (mean 12.6 units) p less than 0.001). The relative isoenzyme distribution as represented by NAG-B/Total NAG percentage is however similar in both groups, 24.27 and 20.38% respectively. NAG-B excretion in 6 SCI patients with upper UTI was not significantly higher than in 12 SCI patients with lower UTI. NAG-B/Total NAG percentage was significantly different between these two groups (35.3% and 24.98% respectively, p less than 0.05). There was no significant difference in NAG-B excretion or NAG-B/Total NAG percentage between control SCI patients and those with lower UTI. The results indicate that there is a non-selective increase in urinary NAG excretion in control SCI patients and those with lower UTI. In SCI patients with upper urinary UTI there is a selective increase in NAG-B excretion. The overlap in enzyme values between the different groups suggests that the test may not be clinically useful in localising the site of UTI.

Acetylglucosaminidase↗
PubMed2003

Mild dehydration: a risk factor of urinary tract infection?

Bacterial growth in the urinary tract is usually prevented by host factors including bacterial eradication by urinary and mucus flow, urothelial bactericidal activity, urinary secretory IgA, and blood group antigens in secretions which interfere with bacterial adherence. Bacterial eradication from the urinary tract is partially dependent on urine flow and voiding frequency. Therefore, it seems logical to postulate a connection between fluid intake and the risk of urinary tract infections (UTIs). However, experimental and clinical data on this subject are conflicting. Experimental studies concerning the effect of water intake on susceptibility and course of UTIs were predominantly performed in the 60s and 70s. Despite many open questions, there has been no continuous research in this field. Only few clinical studies producing contradictory results are available on the influence of fluid intake concerning the risk of UTI. One explanation for the inconsistency between the data might be the uncertainty about the exact amounts of fluid intake, which was mostly recorded in questionnaires. So far, there is no definitive evidence that the susceptibility for UTI is dependent on fluid intake. Nevertheless, adequate hydration is important and may improve the results of antimicrobial therapy in UTI. Results of experimental and clinical studies concerning urinary hydrodynamics are the basis for advice given by expert committees to patients with UTI to drink large volumes of fluid, void frequently, and completely empty the bladder. The combination of the behaviourally determined aspects of host defence and not simply increasing fluid intake is important in therapy and prophylaxis of UTI.

Anti-Bacterial Agents↗
PubMed2001

Suppression of superantigen-induced lung injury and vasculitis by preadministration of human urinary trypsin inhibitor.

We examined whether the lung injury produced in rats by intraperitoneal injection of the superantigen, staphylococcal enterotoxin B (SEB), could be inhibited by intravenous preadministration of human urinary trypsin inhibitor (UTI), which exhibits multipotent inhibitory effects on serine proteinases such as plasmin, chymotrypsin, or human leukocyte elastase or cathepsin G, since preliminary experiments showed the ability of UTI to bind lipopolysaccharides and bacterial toxins. For ligand blotting analysis, four kinds of toxins were run on a slab gel and the binding of UTI to the toxins was visualized by immunoblotting. Lung tissue from 26 rats was used for immunohistochemistry using a mouse antirat CD 45 mAb and an antirat macrophage mAb. Lung tissue from 31 rats was used for measurement of myeloperoxidase activity before and after intraperitoneal injection of SEB, after infusion of PBS, UTI, PBS-SEB or UTI-SEB combination. Ten of the 26 rats described above were used for electron microscopy. Rat sera were used for measurement of TNF-alpha. Statistical analysis was performed using the Mann-Whitney U-test. Intraperitoneal injection of SEB caused an increase in the number of punctate areas of haemorrhage on the surface of the lung with time, and histological examination revealed lung injuries with different extents, vasculitis where inflammatory cells were concentrated, and infiltration of numbers of eosinophils into the alveolar septa. However, preadministration of UTI for rats markedly attenuated lung injury and vasculitis induced by intraperitoneal injection of SEB. This revealed, from a marked reduction in the number of inflammatory cells and the extent of injury, a marked inhibition of serum TNF-alpha production and reduction of myeloperoxidase content of rat lungs compared to controls. UTI may have defensive effects to infection by suppressing the early responses of stimulated cells to activated stimulus such as SEB as well as the release of stimulant-mediated cytokines via trapping of bacterial toxins.

Animals↗
PubMed2003

A UK multicentre study of the antimicrobial susceptibility of bacterial pathogens causing urinary tract infection.

OBJECTIVES: To determine the prevalence of resistance amongst urinary tract pathogens against antimicrobials used to treat urinary tract infections (UTIs) in the UK to provide data to help direct empirical therapy. METHOD: During 1999-2000, a total of 1291 bacterial isolates causing UTI were collected from 8 centres in the UK. Isolates were cultured from patients with (1). community-acquired UTI in those less than 65 years old (397), (2). hospital-acquired UTI other than those admitted with pyelonephritis (394), (3). pyelonephritis (108) and (4). community-acquired UTI in those greater than 65 years old (392). After re-identification, MICs for a range of antimicrobials were determined and interpreted using NCCLS procedures and interpretive guidelines. RESULTS: Escherichia coli was the predominant pathogen in all categories but the total percentage for each category varied (56.3-77.3%). The next three pathogens of importance were Enterococcus faecalis, Klebsiella pneumoniae and Proteus mirabilis which varied in prevalence slightly from category to category. The activity of amoxycillin against E. coli (51.3% susceptible) was greatly reduced as a result of beta-lactamase production and only partially restored by the addition of clavulanic acid (78.8% susceptible). Cefuroxime was very active against E. coli using parenteral form breakpoints (97.1% susceptible) but less so using oral form breakpoints (68.6% susceptible). Cefuroxime was inactive against Enterococcus spp. and Pseudomonas spp. Nitrofurantoin was very active against isolates of E. coli (96.3% susceptible) and E. faecalis but not against K. pneumoniae, P. mirabilis or Pseudomonas aeruginosa. Overall susceptibility to trimethoprim ranged from 58.1% to 84.5% for the most prevalent pathogens. Ciprofloxacin was highly active against the UTI pathogens examined in this study with susceptibilities of between 88.6% and 97.7% for the most prevalent pathogens (E. coli, n=864, 97.7% susceptible) and was the only oral agent tested with activity against Pseudomonas spp. CONCLUSION: These data provide much needed information on the prevalence of antimicrobial resistance amongst pathogens currently causing UTI in the UK.

Adolescent↗
PubMed2001

Kinetics of urinary trypsin inhibitor in patients undergoing partial hepatectomy.

BACKGROUND: The kinetics and role of urinary trypsin inhibitor (UTI) in liver surgery are unclear. We investigated the effects of preoperative liver function and the extent of liver resection on postoperative UTI synthesis in the liver after partial hepatectomy. METHODS: Sixty-one consecutive patients who underwent liver resection were the subjects of the study. Plasma and urine UTI, plasma C reactive protein (CRP) and plasma and urine creatinine were measured perioperatively. RESULTS: Although the average plasma UTI level did not change significantly, the average urine UTI level per day showed a change similar to that of the average plasma CRP level, reaching a maximum of approximately eight times the preoperative level on the second postoperative day (86,610 +/- 53,109 U/day). The maximum postoperative increase in urine UTI excretion per day (delta-uUTImax) correlated significantly with the maximum increase in CRP and the increase in creatinine clearance. Multiple regression analysis revealed that delta-uUTImax was significantly and positively correlated with the indocyanine green plasma disappearance rate and operation duration, and negatively correlated with the resection rate. CONCLUSIONS: The postoperative urine UTI level may reflect preoperative liver function and the extent of liver resection after partial hepatectomy.

Adult↗
PubMed1998

Increased prevalence of urinary tract infections and anomalies in infants with pyloric stenosis.

We performed a retrospective analysis of all patients admitted to our institution with a diagnosis of infantile hypertrophic pyloric stenosis (IHPS) during a 10-year period from 1985-95 in order to assess the possible association between IHPS and urinary tract infections (UTIs). All 285 patients with IHPS had radiological or ultrasonographic confirmation of that diagnosis and underwent the Ramstedt procedure. Those who continued to be symptomatic were evaluated for UTI by urine analysis and culture. Positive cases were further evaluated for urinary system anomalies. The male:female ratio of IHPS was 3.4:1. Concomitant UTI was diagnosed in 8 patients by suprapubic aspiration or bladder catheterization. The prevalence of UTI in this series was 2.8%, 20-fold higher than the expected prevalence. Three of the 8 patients with UTI (37.5%) had urinary tract anomalies. These findings suggest an association between IHPS and UTI. We recommend that all IHPS patients be evaluated for UTI and positive cases undergo further evaluation for urinary anomalies.

Female↗
PubMed2002

Adults with pediatric-onset spinal cord injury: part 1: prevalence of medical complications.

OBJECTIVE: To determine the prevalence of medical complications of adults with pediatric-onset spinal cord injury (SCI) and their association with demographic, impairment, and functional limitation factors. METHOD: Structured interview including standardized measures. PARTICIPANTS: Individuals who sustained spinal cord injuries at age 18 years or younger and were 24 years of age or older at interview. OUTCOME MEASURES: Prevalence of medical complications: Urinary tract infections (UTI) requiring intravenous antibiotics or hospitalization (severe UTI), pressure ulcers, hemorrhoids and rectal bleeding, chronic medical conditions, and hospitalizations in the past 3 years. Urinary stones, orchitis or epididymitis, pneumonia, ventilatory assistance, thromboembolism, and latex allergy since injury. Current experience with UTI, bladder and bowel incontinence, bowel program length, constipation or diarrhea, dysreflexia, and hyperhidrosis. RESULTS: Two hundred sixteen individuals were interviewed, with a mean age of injury of 14 years and a mean age at follow-up of 29 years. Most commonly experienced complications were UTI (74%), bowel incontinence (63%), pressure ulcers (44%), autonomic dysreflexia (42%), and respiratory complications (33%). Pressure ulcers were more common in men and latex allergy more common in women. Age at injury was not associated with any of the complications. Older age at interview was associated with orchitis or epididymitis, bowel incontinence, respiratory complications, thromboembolism, and chronic medical conditions; longer duration of injury was associated with these same complications, except for bowel incontinence. Greater neurologic impairment was related to UTI, severe UTI, stones, bowel incontinence, respiratory complications, autonomic dysreflexia, hyperhidrosis, latex allergy, and pressure ulcers. With the exception of latex allergy and UTI, Functional Independence Measure (FIM) scores were associated with the same factors as neurologic impairment. CONCLUSIONS: Medical complications are common sequelae for adults with pediatric-onset SCI. Demographic, impairment, and functional limitation factors are associated with these complications and can be used to identify at-risk individuals.

Adolescent↗
PubMed2002

Prevention of urinary tract infection in patients with spinal cord injury.

BACKGROUND: Urinary tract infection (UTI) is a major cause of morbidity and mortality in individuals with spinal cord injury (SCI). Altered voiding dynamics, use of urinary drainage catheters, and frequent exposure to antibiotic agents predispose individuals with SCI to recurrent episodes of UTI, often with resistant organisms. OBJECTIVE: To evaluate the efficacy of various methods of UTI prevention in the SCI population. These methods include type of bladder management, choice of catheter materials, antiseptic agents, oral antibiotics, and experimental approaches. METHODS: Literature review. FINDINGS: Choosing a method of bladder management that minimizes the use of a foreign body, yet drains the bladder effectively, is the best available means to reduce the risk of UTI. The chief drawback to antimicrobial-coated catheters, topical or intravesicular antiseptic agents, and prophylactic oral antibiotics is that, over time, bacteria become resistant and overcome the obstacles to bladder invasion. Therefore, antiinfective catheter materials, antibiotics, and antiseptic agents are not beneficial for long-term prevention of UTI in persons with SCI. Novel approaches that avoid the use of antimicrobial agents offer hope for patients with recurrent UTI, but these techniques are still in the experimental stage. CONCLUSIONS: Method of bladder management remains the most influential factor in reducing the risk of UTI in persons with SCI. Experimental approaches that inhibit adhesion and biofilm formation by uropathogens are promising.

Bacteriuria↗
PubMed2004

Impact of a urinary tract infection educational program in persons with spinal cord injury.

OBJECTIVE: To test the hypotheses that an educational program reduces the frequency and severity of urinary tract infections (UTIs) in persons with spinal cord injury (SCI) and impacts health beliefs, locus of control, and self-efficacy. DESIGN: Randomized controlled study. METHODS: Fifty-six participants were randomized to patient educational program or control groups after a 5- or 6-month baseline period. The educational program group received written material on UTIs, a self-administered test, a review by nurse and physician, and a follow-up telephone call. Data were collected monthly throughout the baseline period and the 5- or 6-month follow-up period. OUTCOME MEASURE: The measures used were significant urine colony counts (UCCs), number of symptoms and UTIs, episodes of antibiotic treatment for UTIs, and 3 questionnaires (the Health Beliefs Questionnaire, the Multidimensional Health Locus of Control [MHLC] Scale, and a self-efficacy questionnaire). RESULTS: When controlling for baseline counts and the difference between groups at baseline, the treatment group had significantly fewer significant UCCs than did the control group (P = 0.009). A trend also was seen for fewer symptom reports (P = 0.094) and fewer number of antibiotic treatment episodes (P = 0.232) in the treatment group. In addition, whereas the treatment group tended to have higher scores on the internal MHLC Scale (P = 0.066), they also perceived the severity of UTIs as greater than did the control group (P = 0.042) and had lower scores on the self-efficacy questionnaire (P = 0.033). CONCLUSION: This is the first randomized controlled trial to demonstrate a significant reduction in bacterial load in the urine of persons with SCIs and an apparent reduction of symptoms and antibiotic treatment episodes for UTIs using a focused educational program. The increased scores on the internal MHLC Scale suggest that individuals in the treatment group felt that they had more control over their health behavior after receiving a UTI educational intervention.

Adult↗
PubMed2000

Recurrent urinary tract infections in postmenopausal women.

To evaluate factors associated with recurrent urinary tract infection (UTI) in postmenopausal women, we conducted a case-control study comparing 149 postmenopausal women referred to an infectious diseases outpatient clinic who had a history of recurrent UTI (case patients) with 53 age-matched women without a history of UTI (control patients). Each woman completed a questionnaire providing demographic data, history and clinical characteristics of prior infections, and information regarding risk factors for UTI. In addition, each patient underwent a gynecologic evaluation, renal ultrasound and urine flow studies, and blood group and secretor status testing. Three urologic factors-namely, incontinence (41% of case patients vs. 9.0% of control patients; P<.001), presence of a cystocele (19% vs. 0%; P<.001), and postvoiding residual urine (28% vs. 2.0%; P=.00008)-were all strongly associated with recurrent UTI. Multivariate analysis showed that urinary incontinence (odds ratio [OR], 5.79; 95% confidence interval [CI], 2.05-16.42; P=.0009), a history of UTI before menopause (OR, 4.85; 95% CI, 1.7-13.84; P=. 003), and nonsecretor status (OR, 2.9; 95% CI, 1.28-6.25; P=.005) were most strongly associated with recurrent UTI in postmenopausal women. Prospective studies are needed to confirm these observations and to develop approaches for prevention.

Aged↗
PubMed2006

Reducing urinary tract infections among female clean room workers.

OBJECTIVES: A higher prevalence of urinary tract infection (UTI) was observed among clean room workers than among others in our previous study in 2001. We implemented intervention programs for reducing UTI and evaluated their effects 2 years later. METHODS: We conducted an intervention study in four factories in the industrial park where the previous study was conducted and recruited participants from women workers who received annual health examinations at the clinic of the park. The intervention included health education programs during the new employee orientation and seasonal on-the-job training. We also implemented other measures, including placing posters in the workplace and disseminating knowledge of UTI prevention through e-mail and oral communications. One-on-one education was provided to workers who were found to have UTI in the previous study. RESULTS: All the 1666 qualified workers, including 1414 clean room workers and 252 nonclean room workers, agreed to participate. We found a similar prevalence (both 0.8%) of symptomatic UTIs (patients with clinical symptoms, such as voiding frequency, urgency, and burning sensation during voiding) in clean room and nonclean room workers. In the 366 participants who also participated in the previous study, we found a significant decrease in the prevalence of UTI (from 9.8% to 1.6%) and significant increases in the prevalence of water intake and urine voiding, three times or more during a shift (p < 0.001 for all McNemar tests). CONCLUSIONS: The interventions had achieved behavior modification and decreases in the prevalence of UTI.

Adult↗
PubMed2005

Pregnancy outcomes following hospitalization for motor vehicle crashes in Washington State from 1989 to 2001.

This retrospective cohort study evaluated the risk of adverse pregnancy outcomes following motor vehicle crashes during pregnancy. The authors assessed outcomes of pregnant women hospitalized for motor vehicle crashes in Washington State from 1989 to 2001 (n = 582). They used the Injury Severity Score (ISS) to classify 84 severely injured (ISS > or =9), 309 non-severely injured (ISS 1-8), and 189 uninjured (ISS 0) pregnant women and compared them with pregnant women who had not been hospitalized for a motor vehicle crash (n = 17,274). Of pregnant women in motor vehicle crashes, 82.9% were hospitalized and discharged without delivering, and 17.1% delivered at hospitalization. Compared with women not in motor vehicle crashes, severely and non-severely injured women were at increased risk of placental abruption and cesarean delivery, and their infants were at increased risk of respiratory distress syndrome and fetal death. Uninjured women were also at increased risk of preterm labor (relative risk = 7.9, 95% confidence interval: 6.4, 9.8) and placental abruption (relative risk = 6.6, 95% confidence interval: 3.9, 11.2) compared with women not in motor vehicle crashes. Pregnant women hospitalized following motor vehicle crashes are at increased risk of adverse pregnancy outcomes, regardless of the presence or severity of injuries.

Accidents, Traffic↗
PubMed1983

Urinary tract etiology of bloodstream infections in hospitalized patients.

During a 23-month study, we identified 1,233 patients with nosocomial urinary tract infections (UTIs) among 40,718 consecutive admissions by using a standardized, prospective system of hospital-wide surveillance. Nosocomial bloodstream infections (BSIs) occurred in 565 patients, 32 of whom had BSIs originating from UTIs, for an attack rate of 2.7 per 100 patients with nosocomial bacteriuria. Patients with UTIs due to Serratia marcescens were most likely to develop secondary BSIs (rate, 16 per 100) compared to patients with nosocomial UTIs due to other organisms (rate, less than or equal to 4.3 per 100; P less than 0.05). Furthermore, the median interval between documentation of UTI and of secondary BSI was 24 days for patients with infections due to S marcescens compared to one day for the entire group (P less than 0.005). Risk factor analysis indicated that men with UTIs were more likely to develop secondary BSIs than were women (P less than 0.05). Intensified infection control efforts are particularly necessary with high-risk groups such as bacteriuric men--especially among those patients with UTIs due to S marcescens--to reduce the incidence of secondary, hospital-acquired BSIs.

Adult↗
PubMed1988

Properties of Escherichia coli isolates from urinary tract infections in boys.

Fifty-five isolates of Escherichia coli from urine of boys younger than three years of age with urinary tract infection (UTI) were compared with strains from girls of the same age range who had UTI. The frequency of P fimbriae, hemolysin, and type 1C fimbriae, previously described as associated with pyelonephritis (PN) in girls, was also high (76%, 60%, and 31%, respectively) in UTI-associated strains from boys. However, in contrast to isolates from girls, strains from lower UTI in boys did not differ from PN-associated strains regarding these three characteristics. In contrast, aerobactin production was significantly associated with PN compared with lower UTI in both sexes. Serotypes O4 and O6 were overrepresented among all UTI-associated strains from boys and PN-associated strains from girls. This overrepresentation was largely accounted for by three clones, one of which was a new clone identified among the UTI-associated strains from boys.

Age Factors↗
PubMed2006

When do general practitioners request urine specimens for microbiology analysis? The applicability of antibiotic resistance surveillance based on routinely collected data.

OBJECTIVES: We do not know how representative reported levels of resistance to antibiotics in urinary tract infections (UTIs) are as there is wide variation in the rate of urine specimens submitted to microbiology laboratories by general practices. We used a questionnaire to investigate variation in sampling for patients with suspected UTI to explore any systematic bias that may influence interpretation of surveillance data based on routine data. METHODS: We sent a questionnaire to a stratified random sample of general practitioners (GPs) in Wales for self-completion. The GPs were presented with six clinical scenarios and asked about their proposed clinical management. RESULTS: We found that nearly all of the GPs indicated they would request a specimen for scenarios representing a probable UTI in a female child and a probable asymptomatic UTI in pregnancy. There was some variation between the GPs about sampling in a situation of treatment failure in an older woman and recurrent UTI in a male diabetic, with 90% and 81%, respectively, indicating they would request a specimen for these scenarios. The greatest variation was in relation to scenarios concerning the management of a probable uncomplicated UTI, and early patient symptoms with pressure to prescribe, with 56% and 33% of GPs, respectively, indicating they would request a urine specimen for laboratory analysis. CONCLUSIONS: In the light of this reported sampling behaviour, it is likely that there is a systematic bias in surveillance data based on routinely collected data, with samples from cases of uncomplicated UTI being under represented, potentially leading to an overestimation of true resistance rates.

Anti-Bacterial Agents↗
PubMed1993

Effect of periurethral colonization on the risk of urinary tract infection in healthy girls after their first urinary tract infection.

We examined whether periurethral colonization with bacterial pathogens predicts recurrent urinary tract infection (UTI) in girls at risk for infection. Periurethral and urine cultures were obtained weekly from each of seven healthy toilet-trained girls (3 to 6 years of age, normal urinary tract) during the 6 months after their first UTI, when the risk of UTI is 35%. Periurethral and urine isolates of Escherichia coli were grouped into electrophoretic types (ETs) by multilocus enzyme electrophoresis. Fifty-three (43%) of the 122 periurethral cultures were positive for a pathogen (median, 6 positive cultures/patient). Two patients each experienced 2 UTI. Positive periurethral cultures were as common in the five uninfected patients as in the two infected patients (9 of 32 vs. 44 of 90, P = 0.06). In only 1 of the 4 UTI was the infecting organism detected on the periurethra in the 2 weeks prior. Multilocus enzyme electrophoresis of the 104 periurethral and urine E. coli isolates from the 7 patients revealed 22 ETs. Such a diversity of ETs suggests that the flora of the periurethral region is colonized by multiple E. coli strains and is constantly changing in clonal composition. Five E. coli strains (ETs) associated with the initial UTI were detected again on the periurethra of 3 patients during surveillance but did not ascend to cause infection. Thus the mere presence of a pathogen on the periurethra is not by itself a risk factor for UTI.

Bacteria↗
PubMed1997

Urinary tract infections in young febrile children.

UTI is a common and important clinical problem in infants and young children, with a prevalence of 5.3% among febrile infants seen in our Emergency Department. White females with rectal temperature > or = 39 degrees C are at particularly high risk (prevalence, 17%). Several studies have highlighted the limitations of the standard urinalysis for identifying UTI in infants and young children and have recommended performance of both urinalysis and urine culture. Alternative methods such as dipstick urinalysis, although attractive because of ease of performance, are inadequate as a screen for UTI. Hemocytometer WBC counts of an uncentrifuged urine specimen can be performed in an office or hospital-based laboratory with minimal training. Performance of Gram-stained smears, however, is most appropriate for the hospital-based laboratory. In the hospital setting where both tests can readily be performed, the positive predictive value of the combination of pyuria and bacteriuria (85%) allows prompt institution of antimicrobial therapy before culture results are available, whereas the lower positive predictive value of the single finding of either pyuria or bacteriuria (40%) justifies delaying treatment decisions until culture results are available. In the office setting where hemocytometer counts can easily be performed, culturing only specimens with pyuria and those of children presumptively treated with antimicrobials will result in the identification of almost all patients with true UTI, sparing large health care expenditures. Although the urine culture is traditionally regarded as the gold standard of UTI, positive urine cultures may occur secondary to contamination or in cases of ABU, leading to a false diagnosis of UTI. In contrast we found pyuria to be a reliable marker to discriminate infection from colonization of the urinary tract. The sustained absence of an inflammatory response, on repeat UA within 24 h, constitutes strong evidence that infection is absent. Management of ABU is controversial; many experts recommend withholding antibiotics because eradication of low virulence organisms may be followed by colonization with more virulent species that cause pyelonephritis. Preliminary results of our ongoing treatment trial suggest that management of young febrile children with UTI as outpatients receiving oral cefixime is as efficacious as inpatient management with intravenous cefotaxime. Results of renal ultrasound and DMSA scan at the time of infection have not modified management in any patient. Accordingly selective rather than routine performance of ultrasound is recommended. A voiding cystourethrogram at 1 month and a DMSA scan 6 months later have been valuable in identifying patients with vesicoureteral reflux and renal scarring, respectively. Among patients initially identified as having acute pyelonephritis, the incidence of renal scarring at 6 months has been substantially more frequent (approximately 40%) than we had expected. However, the long term implications of small scars identified with renal scintigraphy remain to be determined.

Anti-Bacterial Agents↗