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Sterile Pyuria in Patients Admitted to the Hospital with Infections Outside of the Urinary Tract

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Sterile Pyuria in Patients Admitted to the Hospital with Infections Outside of the Urinary Tract J Am Board Fam Med: first published as 10.3122/jabfm.2014.01.130084 on 3 January 2014. Downloaded from ORIGINAL RESEARCH Sterile Pyuria in Patients Admitted to the Hospital With Infections Outside of the Urinary Tract Jared B. Hooker, MS2, James W. Mold, MD, MPH, and Satish Kumar, MD Objectives: The objective of this study was to determine the incidence, associations, evaluation, and management of pyuria in patients admitted to the hospital with nonurinary infections. Methods: This study abstracted inpatient records of consecutive patients hospitalized for pneumonia, intra-abdominal infections, female genital tract infections (GYN infections), bacterial septicemia, and enteritis in the pediatric and adult medical and surgical units at an academic medical center. Results: The study population included 210 patients (66 children; 144 adults). Nearly one-third had >5 white blood cells (WBCs) per high-power field (pyuria). Pyuria was more common in women (P < > and less common in patients with pneumonia (P (001. ؍ and in patients with GYN infections (P (001. .001). Cultures were performed on 18 of 19 children (94.7%) and 26 of 43 adults (60.5%) with pyuria. Of those, 11.1% of children and 42.1% of adults had a positive culture, and all but one of those met criteria for a urinary tract infection. Excluding patients with GYN infections, only 18.8% of patients with pyuria had a positive culture. Of the 44 patients with pyuria who were cultured, a positive culture was moderate or large amounts of bacteria in the urine ,(01. ؍ associated with having a GYN infection (P The absolute number of WBCs or red blood cells in .(004. ؍ and a positive urine nitrite (P ,(005. ؍ P) the urine and the presence of casts, proteinuria, and leukocyte esterase were not associated with posi- tive culture or urinary tract infection. Neither pyuria nor a positive culture was related to temperature, systemic WBC count, or serum albumin, blood urea nitrogen, or creatinine. Conclusions: Sterile pyuria of uncertain cause is common in patients admitted to the hospital with acute nonurinary infections. (J Am Board Fam Med 2014;27:97–103.) Keywords: Antibiotics, Fever, Patient Admission, Pyuria, Urinary Tract Infections Urinalysis is a test commonly ordered at admission have pyuria, which can confuse the admitting phy- http://www.jabfm.org/ to a hospital, especially when the patient has a sicians, who sometimes alter their antibiotic choice febrile illness. In most cases it provides useful in- based on the abnormal urinalysis even when the formation, but it can sometimes be misleading. evidence for urinary tract infection (UTI) is weak. One of the authors (JWM) has observed that pa- Others have documented that sterile pyuria can tients admitted to the hospital with acute infectious occur in both adults and children with pneumonia illnesses unrelated to the urinary tract frequently and other acute febrile illness, suggesting that some feature of these illnesses or fever itself might cause on 1 October 2021 by guest. Protected copyright. leakage of white blood cells (WBCs) into the This article was externally peer reviewed. urine.1–7 In fact, sterile pyuria has many causes Submitted 6 March 2013; revised 10 July 2013; accepted 1,8,9 15 July 2013. (Table 1). However, the incidence, predictors, From the College of Medicine (JBH), the Department of and clinical implications of pyuria in patients ad- Family and Preventive Medicine (JWM), and the Division of Nephrology, Department of Internal Medicine (SK), Uni- mitted to the hospital with infections outside of the versity of Oklahoma Health Sciences Center, Oklahoma urinary tract have not been studied. Believing that City. Funding: Funding was provided by the Department of more information about this phenomenon might help Family and Preventive Medicine, University of Oklahoma physicians make better initial antibiotic choices, we Health Sciences Center. Conflict of interest: none declared. undertook this study to estimate the incidence of Corresponding author: James W. Mold, MD, MPH, Depart- pyuria at the time of hospital admission in patients ment of Family and Preventive Medicine, University of Okla- homa Health Sciences Center, 900 NE 10th Street, Oklahoma with acute infections outside of the urinary tract City, OK 73104 (E-mail: [email protected]). and to gather information that could help clinicians doi: 10.3122/jabfm.2014.01.130084 Sterile Pyuria With Infections Outside of the Urinary Tract 97 J Am Board Fam Med: first published as 10.3122/jabfm.2014.01.130084 on 3 January 2014. Downloaded from Table 1. Some Reported Causes of Sterile Pyuria and the Tests Generally Used to Diagnose Them Cause Evaluation Infectious causes Perinephric abscess Ultrasound; CT Renal tuberculosis Urine TB culture and PCR Fungal infections of the kidneys Gram stain; fungal culture Partially treated pyelonephritis History; CT Fungal infections of the bladder Gram stain; fungal culture Partially treated cystitis History Contamination of urine with antiseptic Repeat urinalysis Prostatitis Prostate exam Urethritis History; urine PCR; chlamydia culture Cervicitis Vaginal exam; cervical culture Vaginitis Vaginal exam; wet prep/KOH Appendicitis, diverticulitis US; CT Q fever History; serology Noninfectious causes Crystal nephropathy and nephrolithiasis CT, IVP Lithium or heavy metal nephropathy History; lithium level; heavy metal tests Renal papillary necrosis (diabetes, sickle cell disease, analgesic nephropathy) Renal sarcoidosis Urinalysis, IVP; US; CT Polycystic kidney disease Renal biopsy Renal transplant rejection US; CT Interstitial nephritis History; renal biopsy Genitourinary malignancy Urine eosinophils, renal biopsy Interstitial cystitis CT; cystoscopy Systemic lupus erythematosis, other autoimmune diseases Cystoscopy Kawasaki disease ESR; ANA, anti-DNA History; physical exam ANA, antinuclear antibodies; CT, computed tomography; ESR, erythrocyte sedimentation rate; KOH, potassium hydroxide; IVP, intravenous pyelogram; PCR, polymerase chain reaction; TB, tuberculosis; US, ultrasound. http://www.jabfm.org/ make better initial evaluation and treatment deci- abdominal infection, (4) enteritis, or (5) female sions in such cases. genital tract (GYN) infections. We chose to look at We specifically set about to answer the following patients with pneumonia and septicemia because questions about patients admitted to the hospital prior studies have suggested a link between these with non-urinary tract infections: (1) What are the infections and sterile pyuria, sometimes referred to incidences of pyuria, bacteriuria, and UTI? (2) as “febrile pyuria.”1,2 Intra-abdominal infections, on 1 October 2021 by guest. Protected copyright. What clinical factors are associated with pyuria in female GYN infections, and enteritis were selected these patients? and (3) How often and in what ways because they might cause external inflammation of does pyuria impact management decisions? the urinary tract. We excluded patients with diag- noses of end-stage renal disease, genitourinary Methods stones, sickle cell disease, malignant hypertension, Data Collection and sarcoidosis—conditions known to cause sterile From a list of consecutive patients (both adults and pyuria—at admission or discharge. We also ex- children) discharged from the medical and surgical cluded patients who did not have a urinalysis within services of an academic medical center between 24 hours of admission, lacked a history and physical June 1 and September 30, 2011, we retrospectively examination in their record, or had an indwelling identified and abstracted the medical records of all catheter at the time of admission. patients with the following diagnoses at discharge: After orientation to the electronic medical re- (1) pneumonia, (2) bacterial septicemia, (3) intra- cord (MediTech, Westwood, MA) and abstraction 98 JABFM January–February 2014 Vol. 27 No. 1 http://www.jabfm.org J Am Board Fam Med: first published as 10.3122/jabfm.2014.01.130084 on 3 January 2014. Downloaded from training, one author (JBH) abstracted the data from colony-forming units/mL of a single bacterial spe- the medical records into a spreadsheet (Microsoft cies if the urine was obtained using the clean catch Excel; Microsoft Corp., Redmond, WA) and then (CC) method and at least 50,000 colony-forming imported them into a statistical analysis program units/cm3 of a single bacterial species if the urine (Statistix 9; Analytical Software, Tallahassee, FL). was obtained by catheterization (cath). Urine cul- A subset of 10% of the records was reviewed by tures with multiple bacterial species were consid- another author (JWM) to check the accuracy of the ered negative. We defined sterile pyuria as Ͼ5 abstractions and direct further training. The abstrac- WBCs/HPF with a negative urine culture. A UTI tions captured demographic data (age, race, sex, pri- was defined as the presence of a positive urine mary insurance type, habitat before admission); culture and one or more of the following urinary weight and temperature at admission; presenting symptoms or signs: frequency, dysuria, urgency, symptoms (categorized by organ system); specific uri- incontinence, flank pain, abdominal pain, lower ab- nary symptoms and signs (frequency, dysuria, ur- dominal tenderness, or CVA tenderness. gency, incontinence, flank pain, abdominal pain, The study was approved by the University of lower abdominal tenderness, and costovertebral an- Oklahoma Health Sciences Center Institutional gle [CVA] tenderness); WBC count; serum creati- Review Board,
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