Urogenital Tract Infection

Molecular Defense Mechanisms during Urinary Tract Infection: Se Young Choi, In Ho Chang; Urogenit Tract Infect 2015;10(2):57-66. Published online October 31, 2015

Abstract PDF: The urinary tract is a common site of infection. The complete mechanisms of urinary tract infection (UTI) are still unknown. In general, the strategies of the uropathogenic Escherichia coli are adherence, motility, iron acquisition, toxin, and evasion of host immunity. Host immune responses play a significant part in defense of UTI. Various antimicrobial peptides (AMPs) including defensins, cathelicidin, hepcidin, ribonuclease 7, lactoferrin, lipocalin, Tamm-Horsfall protein, and secretory leukocyte proteinase inhibitor help to prevent UTI by modulation of innate and adaptive immunity. Toll-like receptors (TLRs) play an important role of microorganism identification in innate immunity. Stimulation of TLRs on the cell membrane by ligand of bacteria triggers production of inflammatory chemokines, cytokines, and AMPs. These mechanisms are an attempt to defend the urinary tract against UTI.

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Uropathogens Based on Antibiotic Susceptibility: Sang Wook Lee, Young Ho Kim; Urogenit Tract Infect 2015;10(2):67-73. Published online October 31, 2015

Abstract PDF: Urinary tract infections are one of the most commonly encountered infections in clinical practice. Due to the emergence of and increase in urinary tract bacteria that are resistant to trimethoprim-sulfamethoxazole, penicillin, cephalosporins, and fluoroquinolones, selection of appropriate antibiotics in treatment of these infections is important. In addition, the emergence of extended-spectrum betalactamase- producing organisms makes antibiotic selection difficult. This article provides a review of disease-specific uropathogens and their susceptibilities to antimicrobial agents.

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Changing Epidemiology of Extended Spectrum Beta-Lactamases Pathogen of Urinary Tract: Taesoo Choi, Koo Han Yoo, Sun-Ju Lee; Urogenit Tract Infect 2015;10(2):74-83. Published online October 31, 2015

Abstract PDF: This review covers the recent findings on extended spectrum beta-lactamases (ESBL) pathogens, focusing on the epidemiology of infection due to this pathogen. Use of ESBL is growing rapidly and widely. CTX-M-15 producing ESBL Escherichia coli is the most commonly encountered in clinical practice. In general, ESBL infections are represented by urinary tract infections, but they can also cause fatal infections involving the vascular system and central nervous system. Because E. coli is a common colonizer of normal intestine, increasing prevalence of ESBL-producing pathogens is particularly troublesome. In a situation where ESBLs are disseminated in the community, the ideal control of this multidrug-resistant pathogen will be challenging. Precise data on the prevalence and risk factors of ESBL-producing microorganism are still undetermined. More epidemiological studies are needed for the question to be answered. In order to maximize efficiency of treatment, information on the trend of increasing numbers of ESBLs is also needed on persistence of ESBLs in carriers as well as better understanding of how antibiotic treatment and other risk factors affect their persistence and further dissemination. The global emergence of multidrug-resistant ESBL pathogen has recently led to critical treatment problems. Early detection, adequate antibiotic therapy, and effective prevention are necessary for achievement of a safe community.

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Management of Extended-Spectrum Beta-Lactamase-Positive Gram-Negative Bacterial Urologic Infections: Yong Kwan Lim, Mi-Kyung Lee, Tae-Hyoung Kim; Urogenit Tract Infect 2015;10(2):84-91. Published online October 31, 2015

Abstract PDF: Extended-spectrum beta-lactamases (ESBLs) are enzymes that confer increased resistance to commonly used antibiotics. The prevalence rates of ESBL producing bacteria are increasing, and the associated increase in morbidity and mortality is becoming a public health concern. ESBL producers are emerging as an important cause of urinary tract infection (UTI) and empirical therapy should therefore be carefully selected for patients with UTI. Fosfomycin or nitrofurantoin would be an appropriate choice for empirical therapy of uncomplicated UTI. Ertapenem or cefepime might be recommended for initial empirical therapy patients suspected of having complicated UTI.

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Proposed New Pathophysiology of Chronic Prostatitis/Chronic Pelvic Pain Syndrome: In-Chang Cho, Seung Ki Min; Urogenit Tract Infect 2015;10(2):92-101. Published online October 31, 2015

Abstract PDF: The most common type of prostatitis is category III, also known as chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS). The current National Institutes of Health definition of CP/CPPS includes genitourinary pain with or without voiding symptoms in the absence of uropathogenic bacteria, as detected by standard microbiological methods, or other identifiable causes such as malignancy. Many different etiologies and mechanisms of pathogenesis of CP/CPPS have been proposed with a suggested role for immunological, neurological, endocrine, and psychological factors. We examined the data supporting the role of each of these areas and also examined the possible interrelationship of these factors in producing the symptoms of CP/CPPS. Prostatitis types IIIa and IIIb are classified according to the presence of pain without concurrent presence of bacteria; however, it is becoming more evident that, although levels of bacteria are not directly associated with levels of pain, the presence of bacteria might act as the initiating factor that drives primary activation of mast-cell-mediated inflammation in the prostate. The gate control theory provides a neurologic basis for the influence of both somatic and psychological factors on pain. Acceptance of chronic pain as a diagnosis may be difficult for the clinician and patient, however it is an important concept in the care of CP/CPPS, which enables the use of pain-directed therapies. Management of CP/CPPS will remain challenging; however, this review provides a better understanding of the condition and improved management strategies based on the newest evidence and concepts available.

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Clinical Significance of National Institutes of Health-Chronic Prostatitis Symptom Index Pain Score in Patients with Benign Prostatic Hyperplasia: Chang Min Lee, Jae Mann Song, Kwang Jin Kim, Tae Wook Kang, Seung Hoon Ryang, Yun Byung Chae, Hyun Chul Chung, Jae Hung Jung; Urogenit Tract Infect 2015;10(2):102-107. Published online October 31, 2015

Abstract PDF: Purpose: Many benign prostatic hyperplasia (BPH) patients were accompanied by pelvic pain apart from urinary symptoms. Therefore, we evaluate the treatment outcomes of alpha-blockers via a change of international prostate symptom score (IPSS) according to pain score of the National Institutes of Health Chronic Prostatitis Symptom Index (NIH-CPSI).

Materials and Methods: A total of 356 male patients with BPH from March 2011 to May 2014 were analyzed retrospectively. Prostate specific antigen, prostate volume, IPSS, NIH-CPSI, international index of erectile function (IIEF-5), and uroflowmetry were collected. Patients were categorized according to 2 groups based on the presence and severity of pain and baseline characteristics and treatment outcomes were analyzed.

Results: Two hundred twenty-nine patients (64.3%) reported pain/discomfort on NIH-CPSI. Mean IPSS, mean voiding symptoms, mean storage symptoms on IPSS, and mean IIEF-5 showed a significant difference in groups 1A and 1B. Logistic regression analysis showed that NIH-CPSI pain score was a significant predictive factor for severe IPSS (odds ratio, 2.830; 95% confidence interval, 1.307-6.129). After treatment for 3 months, improvement of IPSS, voiding symptoms, storage symptoms, and quality of life was observed in all groups (p=0.001, p<0.001, p=0.026, p<0.001, p<0.001, p<0.001, p<0.001, p<0.001). Group 2B (pain score>5) showed greater improvement of symptoms and statistically significant difference compared with group 2A (pain score ≤5) (p=0.029, p=0.026).

Conclusions: We suggest that the presence and severity of pain score are helpful for therapeutic efficacy in patients with BPH.

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Risk Factors of Sepsis in Obstructive Acute Pyelonephritis Associated with Urinary Tract Calculi: Chae Hong Lim, Jae Seung Hwang, Dae Ji Kim, Seok Heun Jang, Jeong Hwan Son, Dae Sung Cho, Jae Won Lee; Urogenit Tract Infect 2015;10(2):108-111. Published online October 31, 2015

Abstract PDF: Purpose: The aim of this study is to identify the risk factors for development of sepsis in patients with obstructive acute pyelonephritis (APN) associated with urinary tract calculi.

Materials and Methods: Between January 2004 and December 2013, 73 patients with obstructive APN associated with upper urinary tract calculi were admitted to our institution. Medical records of 73 patients (14 men and 59 women, mean age of 57 years) were reviewed retrospectively. The risk factors for sepsis were analyzed using multivariate logistic regression analysis.

Results: Of 73 patients, 37 (50.7%) developed sepsis. Old age and history of hypertension were more common in the sepsis group than in the non-sepsis group (p＜0.001 and p=0.018). The white blood cell count, neutrophil count, plateletto- lymphocyte ratio, neutrophil-to-lymphocyte ratio (NLR), and C-reactive protein level were significantly higher in the sepsis group (p=0.011, p=0.001, p=0.042, p＜0.001 and p=0.006, respectively). Lymphocyte count, platelet count, and albumin level were significantly lower in the sepsis group (p＜0.001, p=0.008 and p＜0.001, respectively). Multivariate logistic regression analysis indicated that old age (odds ratio [OR], 2.13; p=0.023), decrease in serum albumin level (OR, 4.27; p=0.041), and high NLR (OR, 3.83; p=0.037) were independent risk factors for development of sepsis.

Conclusions: Elderly patients with obstructive APN associated with urinary tract calculi who have low serum albumin levels and high NLR should be treated carefully against development of sepsis.

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Change of Antibiotic Resistance to the Causative Organisms of Pelvic Wound Infection for Recent 5 Years: Yoo Seok Kim, Soon Ki Kim, In-Chang Cho, Jin Soo Ko, Gyeong In Lee, Seung Ki Min; Urogenit Tract Infect 2015;10(2):112-119. Published online October 31, 2015

Abstract PDF: Purpose: We researched microbial profiles and the antimicrobial resistance profile of wound infection of the pelvic area in Korea for the recent 5 years in order to provide useful information on the choice of adequate drugs in the treatment of pelvic wound infection.

Materials and Methods: We retrospectively analyzed 211 pelvic wound culture samples and their antimicrobial resistance in 198 in- or out-patients of the Urology and Plastic surgery department from January 2010 to December 2014.

Results: Of the total samples, Staphylococcus aureus was isolated most frequently (35.3%), followed by Escherichia coli (15.1%), Staphylococcus epidermidis (12.6%), Staphylococcus haemolyticus (12.6%), Staphylococcus lugdunensis (8.4%), Pseudomonas aeruginosa (6.7%), Enterococcus spp. (4.2%), and Streptococcus spp. (3.3%). There were no notable changes of bacterial distribution for 5 years. For Gram-positive isolates, the oxacillin resistance rate for Gram-positive bacteria was 42.6% and showed an increasing tendency for the recent 5 years. Piperacillin, rifampicin, and vancomycin had low resistance for Gram-positive bacteria. Carbapenems, piperacillin/tazobactam had low resistance for Gram-negative bacteria. The Gram-positive organisms were more sensitive to many antibiotics in contrast to the Gram-negative organisms.

Conclusions: Of varied causative organisms and susceptibility of the pelvic wound site, the most frequently infected organisms of the pelvic area were S. aureus, followed by E. coli. The methicillin resistive S. aureus (MRSA) incidence showed a tendency to increase yearly, thus selection or early change of antibiotics considering MRSA is recommended if the antibiotic response is poor. Gram-negative bacteria has a higher resistance rate compared with Gram-positive bacteria and had carbapenems and piperacillin/tazobactam.

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Characteristics of Patients Who Visited the Emergency Room after Prostate Biopsy: Single Center Retrospective Study: Seung Chan Jeong, Seungsoo Lee, Jae Min Chung, Sang Don Lee; Urogenit Tract Infect 2015;10(2):120-125. Published online October 31, 2015

Abstract PDF: Purpose: To educate patients and prevent biopsy-related complications, it is helpful to understand the causes for visiting the emergency room (ER). Therefore, we want to analyze the causes and factors of complications that cause patients to visit the ER after prostate biopsy.

Materials and Methods: We conducted a study of in-patients who visited the ER of Pusan National University Yangsan Hospital after prostate biopsy from December 2008 to July 2015. Age, postoperative interval before visiting the ER, Charlson comorbidity index (CCI) score, symptoms in ER, prostate size, pathologic result, and number of biopsy cores were analyzed retrospectively.

Results: Among all 1,694 cases of patients who had undergone prostate biopsies during a 7-year period, only 37 patients (2.2%) visited the ER. Diabetes mellitus (DM) is the most common underlying disease among patients with accompanying infection-related symptoms compared to patients with accompanying non-infection- related symptoms (p＜0.001). In univariate analysis, DM (p=0.004) and CCI score (p=0.030) were statistically significant risk factors for infection, but only DM was significant in multivariate analysis (p=0.004). Prostate size (p=0.044) was a significant risk factor for acute urinary retention (AUR) in univariate analysis, but not statistically significant in multivariate analysis. CCI score was a statistically significant risk factor for bleeding (p=0.005 [univariate], 0.035 [multivariate]).

Conclusions: AUR after transrectal ultrasound-biopsy is the most common reason for visiting the ER. CCI score showed correlation with bleeding and DM showed correlation with infection. Consideration of risk factors of complications after prostate biopsy will be helpful to the patients in the treatment and prevention of complication.

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Penile Mass Caused by Mycobacterium tuberculosis: Seung Hoon Ryang, Minseob Eom, Tae Wook Kang, Chang Min Lee, Hyun Chul Chung, Jae Mann Song, Kwang Jin Kim, Jae Hung Jung; Urogenit Tract Infect 2015;10(2):126-129. Published online October 31, 2015

Abstract PDF: Tuberculosis of the penis is rare. The clinical features of penile tuberculosis are usually manifested as ulceration or scars. However, the authors encountered a case of penile tuberculosis that presented as a mass. A painless nodule at the base of the penis was noted in a 63-year-old male patient. Surgical excision was recommended, and pathologic finding revealed granulomatous inflammation in the mass. Acid fast bacilli stain and culture were negative, but a positive result was found in urine polymerase chain reaction for detection of Mycobacterium tuberculosis. He was diagnosed with tuberculosis of the penis and underwent anti-tuberculosis chemotherapy.

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