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THE DIAGNOSIS of URINARY TRACT INFECTION Charles V

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THE DIAGNOSIS of URINARY TRACT INFECTION Charles V SPECIAL ARTICLES THE DIAGNOSIS OF URINARY TRACT INFECTION Charles V. Pryles, M.D. Department of Pediatrics, Boston University School of Medicine, and the Pediatric Service, Boston City Hospital T HE TWO major problems in bacterial in tients with urinary tract infection during fections facing us today are the control this age period may recover with no impair of staphylococcal infections, and the con ment of renal function, or they may die trol of cases of bacillary sepsis.1 Infections during the acute phase of their illness. They due to staphylococci that are resistant to may recover and have latent pyelonephritis almost all existing chemotherapeutic and with impairment of function and a de antibiotic agents are prevalent in hospital creased renal reserve, or they may have an patients and are especially common in intermittent or recurrent or progressive in wound infections. Bacillary sepsis, on the fection with a healing or healed pyelone other hand, makes its greatest impact in phritis and renal insufficiency that fre urinary tract infections and they, too, are quently leads to uremia, hypertension, renal common in hospital patients. Keefer1 has dwarfism, or all three.1 stated, “¿pyelonephritis,whether acute or The lack of clear understanding of the chronic, active or healed or healing, is the pathogenesis, diagnosis and treatment of number one problem in infectious disease infections of the urinary tract is well rec due to bacteria today, and demands con ognized. It is equally well known that the tinuing attention and intensive study . classic syndrome of fever, flank pain, dys it is a problem calling for a high priority uria, frequency and pyuria may be absent of investigation.― in pyelonephritis, and that such disease The morbidity from urinary tract infec may occur as a smoldering chronic infec tions generally is not well appreciated. Few tion in which diagnosis is often overlooked data are available that accurately reflect the until too late. Thus, if the serious conse prevalence of bacteriuria and true pyuria. quences of pyelonephritis are to be averted, However, such infections perhaps rank sec early and more precise recognition of the ond only to respiratory infections in fre presence of such infections is necessary. It quency among patients; they probably out is important, therefore, that criteria be rank all other bacterial disease in children established that may prove helpful to the under 2 years of age.2'3 It is well, then, to clinician in making an early diagnosis of concentrate attention on urinary tract in infection of the urinary tract. fection in infancy and childhood, for it is The development of many new antimi not only one of the most important and crobial agents has emphasized the impor most frequent bacterial infections occurring tance of studying the bacterial flora found in this age group, but it is in this age period in urinary tract infections with great care, that chronic disease begins, and that infec because the selection of therapy will de tions most frequently cause premature pend in part on the species of organisms death and protracted illness. That urinary present in the urine. The two commonest tract infection is frequently associated with organisms isolated from single-type infec congenital abnormalities of the urinary tract tions are Escherichia coli and Staphylococ is well known.4@ The infection may be cus aureus. The other common Gram acute or chronic, unilateral or bilateral. Pa negative organisms that cause urinary tract ADDRESS: Boston City Hospital, 818 Harrison Avenue, Boston 18, Massachusetts. PEDIATRICS, September 1960 441 Downloaded from www.aappublications.org/news by guest on October 1, 2021 442 URINARY TRACT INFECTION infection in declining frequency are Aero diagnosis of urinary tract infection, it may bacter aerogenes, Pseudomonas aeruginosa be useful to advance the following gen and Proteus vulgaris. Aside from staphylo eralizations based on our own experience cocci, enterococci are the commonest Gram and that of others: positive organisms found in urine.1012 Gen era! experience with adult patients indicates Urine as a Culture Medium that 75 to 80% of urinary tract infections Urine is usually an excellent culture me are bacillary in origin, and 20 to 25% are dium for the common pathogens of the coccal in origin. Our own experience with urinary tract. Pasteur was the first to direct children indicates that only 6 to 8% of in attention to this important fact. Thus, if fections are coccal in origin, the remainder small numbers of these bacteria were to be bacillary. In the experience of several clin discharged into the urine from a urinary ics, including our own, roughly three-fourths tract lesion, they would multiply rapidly of acute bacillary infections were caused by to reach a concentration of many thousands a single organism in the acute phase of the of bacteria per milliliter of urine.14 disease. Once a patient, however, has been Further, it has been noted by us and treated with an antimicrobial agent or has others@@that storage of urine at room temp required an inlying catheter or an operation eratures for 2 hours or longer leads to a on the urinary tract, the infection is likely distinct increase in the number of bacteria; to become mixed. A mixed infection may on the other hand, storage of a specimen also be present in a complicated urinary of urine at usual refrigerator temperatures tract lesion, i.e., with some anatomic or (4-5°C) up to 1 week will not alter signifi functional anomaly.10'12 cantly the number of organisms present. The evaluation of organisms in cultures These considerations must be kept in mind of urine has received scant attention. The at all times in the examination of urine significance of any given bacterial strain specimens. has been usually determined by the de monstration of its constancy in the urine in Definition of Pyuria the absence of specific therapy. This method Pyuria is said to be the hallmark of has the obvious disadvantage of requiring pyelonephritis but it alone is not satisfac multiple cultures before therapy, each tory for making a diagnosis of urinary tract taken with meticulous care; even then, the infection. In the first place, there is no gen significance of the findings may remain in eral agreement as to what constitutes pyu doubt. It should be emphasized that the na. Wilson and Schloss15 used the term to mere presence (or absence) of any given designate “¿thepresence of sufficient pus to microorganism is not an adequate basis for cause definite cloudiness of the urine.―They ruling it in or out as a cause of clinical further restricted the term to cases in which urologic disease. It is absolutely necessary the pus cells were not only very numerous that a distinction be made between true on microscopic examination, but were pres bacteriuria, i.e., the presence of bacteria ent in definite clumps. CampbelP6 considers in the urine of the urinary tract, and con three to five cells per low-power micro tamination of the urine during the pro scopic field in an uncentrifuged catheter cedure of collection. The bacterial count specimen to be within normal limits; Helm of the urine has offered a means of resolv holz (cited by Campbell16) has stated that ing the problem.13 two to eight cells per low-power field are normal. It is of no moment if the leukocytes GENERAL CONSIDERATIONS are single or clumped, especially in girls Prior to a discussion of the validity of where vaginal mucus may be the cause of bacterial counts in urine in relation to the clumping. Stevenson17 considers more than Downloaded from www.aappublications.org/news by guest on October 1, 2021 SPECIAL ARTICLES 443 two to four leukocytes per low-power field, febrile condition such as pneumonia, tonsil from an uncentnifuged specimen, as abnor litis, appendicitis, or one of the exanthe mal. mata; or b) to a specific vaginitis, which Others― have defined pyunia as the pres is frequently associated with urethritis; or ence of five or more leukocytes per high c) to contamination from the stool in acute power microscopic field in a centrifuged entenitides. Chown, in addition, reported @specimen of urine. has shown that four children with marked pyunia, but with pyunia defined in this way occurs in one no source for the pyunia detectable at care third to one-half of patients with a true ful post-mortem examination; deaths were bacteriunia (i.e., with more than 100,000 due to extra-renal infection in all cases. organisms/mi of urine), but in only 2% of While sterile pyunia may be uncommon, it those with less than 100,000 organisms/mi may occur in 1) the extreme dehydration of of urine. Even if the criteria of pyunia were pyloric obstruction, low fluid intake, or lowered to three leukocytes per high-power acute toxemia; 2) in trauma caused by in field, the incidence in those with true bac struments or calculi; 3) when infection has teniuria rose by but 10%. In the patients in disappeared but an irritating agent re whom the house staff of the Harvard Medi mains; 4) in chemical inflammation; and 5) cal Service at the Boston City Hospital had in acute ruhnti224 We have diagnosed pyelonephritis on clinical encountered a fair degree of pyunia in sev grounds, pyuria was found in only about eral patients with the last-mentioned dis one-half; 95% of the same patients had bac order. Unless all these sources are ruled terial counts greater than 100,000 organisms out, no case can be considered one of true /ml of urine. pyunia. It is clearly evident, then, that Jackson and associates2° found that 22% pyunia may be of diagnostic value only of 41 adult patients with pyelonephnitis when it is clearly present; its absence from (as determined by histopathologic findings any single specimen cannot be taken as evi in kidneys removed at surgery) had no pus dence of the absence of bacteniunia.
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