Search Results (132)

Background: Urinary tract infections (UTIs) are among the most common hospital- and community-acquired infections, creating a substantial healthcare burden due to recurrence, complications, and rising antimicrobial resistance. Accurate diagnosis and timely antimicrobial therapy are essential. This study aimed to identify trends in the etiology, treatment, and resistance patterns of UTIs through a retrospective analysis of urine isolates processed at the Laboratory of Microbiology at University Hospital St. George in Plovdiv, the largest tertiary care and reference microbiology center in Bulgaria, between 2017 and 2022. Materials and Methods: A retrospective single-center study was performed at the hospital’s Microbiology Laboratory. During the study period, 74,417 urine samples from 25,087 hospitalized patients were screened with the HB&L UROQUATTRO system. Positive specimens were cultured on blood agar, Eosin-Methylene Blue, and chromogenic media. Identification was performed using biochemical assays, MALDI-TOF MS, and the Vitek 2 Compact system. Antimicrobial susceptibility testing included disk diffusion, MIC determination, broth microdilution (for colistin), and Vitek 2 Compact, interpreted according to EUCAST standards. Descriptive analysis and temporal resistance trends were evaluated with regression models, and interrupted time-series analysis was applied to assess COVID-19-related effects. Results: Out of 10,177 isolates, Gram-negative bacteria predominated (73%), with Escherichia coli, Klebsiella pneumoniae, and Proteus mirabilis as the leading pathogens. Among Gram-positives, Enterococcus faecalis was the most frequent. In the post-COVID-19 period, ESBL production increased in E. coli (34–38%), K. pneumoniae (66–77%), and P. mirabilis (13.5–24%). Carbapenem resistance rose in K. pneumoniae (to 40.6%) and P. aeruginosa (to 24%), while none was detected in E. coli. Colistin resistance increased in K. pneumoniae but remained absent in E. coli and P. aeruginosa. High-level aminoglycoside resistance in E. faecalis was stable (~70%), and vancomycin resistance in E. faecium rose from 4.6% to 8.9%. Conclusions: Both community- and hospital-acquired UTIs in Southeastern Bulgaria are increasingly linked to multidrug-resistant pathogens, particularly ESBL-producing and carbapenem-resistant Enterobacterales. Findings from the region’s largest referral center highlight the urgent need for continuous surveillance, rational antibiotic use, and novel therapeutic approaches. Full article

Background/Objectives: Urinary tract infections (UTIs) caused by extended-spectrum beta-lactamase (ESBL) Enterobacterales have become more frequent. Therefore, strategies for assessing the risks posed by ESBL-producing infections have been developed, creating the need for local validation. The aim of this study was to validate the scoring system designed by Tumbarello et al. to identify ESBL producers in patients with a UTI that require hospital care in a region with a high prevalence of ESBL Escherichia coli. Methods: A retrospective cohort study was conducted in a third-level hospital in Bogotá (Colombia) between 2013 and 2020.The study included 817 patients, who were hospitalized due to pyelonephritis and treated with cefuroxime (the first-line antibiotic according to local guidelines), with an ESBL frequency of 9.68%. Diagnostic performances were estimated for a modified version of Tumbarello’s score (omitting admission from another healthcare facility) evaluating the area under the curve (AUC) for ESBL presence with respect to resistance to second- and third-generation cephalosporins. Results: With an index cut-off of ≥6, the score showed a sensitivity of 18% and a specificity of 83%. The AUC for this cut-off was 0.47. This threshold index could not efficiently predict either third- (AUC = 0.49) or second-generation cephalosporin resistance (AUC = 0.51). Conclusions: In Colombia, a region with a high prevalence of ESBL E. coli producers, as the use of the Tumbarello index would result in excessive utilization of wide-spectrum antibiotics, it is not recommended in this specific scenario for UTIs. Further studies are required in order to develop accurate tools to assess the risk of ESBL producers in high-prevalence settings. Full article

Background and Clinical Significance: Retained intrarenal foreign bodies are rare adverse events after endourological stone surgery. Guidewire fracture or detachment is uncommon and can trigger infection, obstruction, or encrustation if unrecognized. We report antegrade percutaneous snare retrieval of a retained hydrophilic guidewire tip and provide a concise literature review (seven PubMed-indexed intrarenal cases identified by a structured search) to inform diagnosis, management, and prevention. We also clarify the clinical rationale for an antegrade versus retrograde approach and the sequencing of decompression, definitive stone management, and stenting in the context of sepsis. Case Presentation: A 75-year-old woman with diabetes presented with obstructive left pyelonephritis from ureteral and renal calculi. After urgent percutaneous nephrostomy, she underwent semirigid and flexible ureteroscopic lithotripsy with double-J stenting; the nephrostomy remained. During routine tube removal, the stent was inadvertently extracted. Seven days later she re-presented with fever and flank pain. KUB and non-contrast CT showed a linear 4 cm radiopaque foreign body in the left renal pelvis with dilatation. Under local anesthesia and fluoroscopy, a percutaneous tract was used to deploy a 35 mm gooseneck snare and retrieve the distal tip of a hydrophilic guidewire (Sensor/ZIP-type). Inflammatory markers were normalized; the nephrostomy was removed on day 5; six-week imaging confirmed complete clearance without complications. Conclusions: Retained guidewire fragments should be suspected in postoperative patients with unexplained urinary symptoms or infection. Cross-sectional imaging confirms the diagnosis, while minimally invasive extraction—preferably an antegrade percutaneous approach for rigid or coiled fragments—achieves prompt resolution. This case adds to the seven prior PubMed-indexed intrarenal reports identified in our review, bringing the total to eight, underscoring prevention through pre-/post-use instrument checks, immediate fluoroscopy when withdrawal resistance occurs, and structured device accounting to avoid “never events.” Full article

Background: To identify clinical predictors of early recovery in patients with stone-induced systemic inflammatory response syndrome (SIRS) undergoing emergency decompression and compare the short-term inflammatory and renal function outcomes between retrograde ureteral stenting (RUS) and percutaneous nephrostomy (PCN). Method: We retrospectively evaluated data from 178 patients with stone-induced SIRS who were treated with RUS (n = 98) or PCN (n = 80) between 2011 and 2020. Early recovery was defined as readiness for discharge or no fever relapse within 3 days after drainage. Results: Univariate and multivariate logistic regression analyses identified significant predictors, and clinical outcomes were compared based on drainage methods. Univariate analysis showed that diabetes mellitus (p = 0.009), mid (p = 0.014) and upper (p = 0.017) stone locations, stone size of 10–20 mm, and renal stones were associated with early recovery, whereas female sex (p = 0.01) predicted poorer outcomes. In multivariate analysis, diabetes mellitus (p = 0.031), as well as mid (p = 0.007) and upper (p = 0.026) stone locations, remained favorable predictors, and female sex (p = 0.036) remained a negative predictor. PCN was associated with a transient increase in leukocyte count but facilitated earlier creatinine recovery compared with RUS. Conclusions: Female sex was an independent predictor of failure to achieve early recovery after urgent decompression, whereas diabetes mellitus and proximal ureteral stone location were independent predictors of early recovery. Baseline clinical factors were the main determinants of early recovery, supporting management tailored to these factors. Full article

Background and Objectives: The causes and clinical outcomes of renal perfusion abnormalities occurring after para-aortic lymphadenectomy (PANDx) for gynecologic malignancies are unknown. We investigated the potential involvement of accessory renal artery (ARA) obstruction in their development by reassessing perioperative contrast-enhanced computed tomography (CECT). Materials and Methods: This retrospective study investigated a clinical database to identify urinary contrast defects using CECT in all patients who had undergone PANDx between January 2020 and December 2024. The perfusion defects in the kidney detected by CECT were extracted by a gynecologic oncologist and evaluated by a radiologist and urologist for suspected obstruction of ARAs. Results: Postoperative renal contrast defects were observed in 3.8% (6/157) of patients. Renal parenchymal fibrosis, cortical atrophy, and parenchymal thinning were observed as universal findings in all patients showing renal contrast defects. In five of the six cases, ARAs supplying the infarcted renal segments were identified on preoperative CECT, and arterial obstruction was confirmed on postoperative imaging. The remaining case was considered to be latent pyelonephritis. All five patients underwent laparotomy, and preoperative CECT failed to detect ARAs. The median resected para-aortic lymph node was 23 nodes (range: 15–33) in five patients, showing no statistically significant difference compared to patients without perfusion abnormalities (p = 0.19). Postoperative serum creatinine levels remained stable. Conclusions: ARA obstruction appears to be a risk factor for segmental renal infarction after para-aortic lymphadenectomy in gynecological malignancies; however, the clinical impact on urinary function may be limited. Awareness of this potential complication is essential for gynecologic oncologists performing PANDx. Full article

Objectives: Acute pyelonephritis (APN) caused by extended-spectrum β-lactamase (ESBL)-positive Enterobacteriaceae poses a growing therapeutic challenge in children, as carbapenems remain the mainstay of treatment even when susceptibility to alternative agents such as amikacin is demonstrated. However, the widespread and inappropriate use of carbapenems can lead to carbapenem resistance. The aim of this study was to compare the clinical efficacy of amikacin and carbapenems in the management of pediatric acute pyelonephritis caused by ESBL-positive Enterobacteriaceae. Methods: We analyzed cases of pediatric acute pyelonephritis caused by ESBL-positive Enterobacteriaceae that were treated with either carbapenems or amikacin over a two-year period. This study compared microbiological cure, clinical improvement, and recurrence rates across the amikacin and carbapenem treatment groups. Results: Fifty-five patients were evaluated. The median age of the patients was 3 years (range, 0.1–13 years). The causative agents were E. coli in 43 cases (78.2%) and Klebsiella spp. in 12 cases (21.8%). All were susceptible to both carbapenem and amikacin in vitro. Twenty patients (36.3%) received a carbapenem and thirty-five (63.7%) received amikacin. Twenty-four (43.6%) had an underlying urological disease. No difference was observed between the groups in terms of microbiological cure, clinical improvement, or recurrence rates. Conclusions: Amikacin may be a potential alternative to carbapenems for treating pediatric ESBL-positive APN when in vitro susceptibility is confirmed. Full article

Introduction: Ureteral stents are widely used in the specialty of urology to preserve renal function and provide ureteral patency in cases of urolithiasis, strictures, malignancy, and trauma. This paper presents a novel application of prophylactic ureteral stents deployed under MRI-guidance for ureteral protection in the setting of in-bore salvage cryoablation therapy for recurrent and metastatic prostate cancer. This is the first known case series of ureteral stent placement using near real-time MRI. Materials and Methods: A retrospective chart review was performed for all patients who underwent MRI-guided ureteral stent placement prior to in-bore cryoablation therapy from 2021 to 2022. Each case was managed by an interdisciplinary team of urologists and interventional radiologists. Preoperative and postoperative data were collected for descriptive analysis. Physics safety testing was conducted on the cystoscope and viewing apparatus prior to its implementation for stent deployment. Results: A total of seven males, mean age 73.4 years (range 65–81), underwent successful prophylactic, cystoscopic MRI-guided ureteral stent placement prior to cryoablation therapy of their prostate cancer. No intraoperative complications occurred. A Grade 2 postoperative complication of pyelonephritis and gross hematuria following stent removal occurred in one case. The majority of patients were discharged the same day as their procedure. Conclusions: This case series demonstrates the feasibility of in-bore cystoscopic aided MRI guidance for ureteral stent placement. Ureteral stents can be used to increase the safety margin of complex cryoablation treatments close to the ureter. Furthermore, by following the meticulous MRI safety protocols established by MRI facility safety design guidelines, MRI conditional tools can aid therapy in the burgeoning interventional MRI space. Full article

Asymptomatic bacteriuria (ASB) is a very frequent condition in kidney transplant recipients (KTRs). Guidelines advise against screening and treatment of ASB beyond the first month after renal transplantation. Here, we report the case of a 40-year-old female KTR with untreated ASB complicated with allograft pyelonephritis with urosepsis and acute kidney injury. The reported case highlights that ASB remains a grey area in the management of KTRs (after the first month), and there is a need for new ad hoc studies to identify which patients should be screened and eventually treated. Until new findings are available, it is suggested not to treat KTRs with ASB; however, if ASB is detected, stricter monitoring and non-antibiotic prophylaxis are necessary to favor prevention or prompt therapy of severe urinary tract infections. Full article

Background/Objectives: Acute obstructive pyelonephritis caused by ureteral calculi is a severe urological emergency that can rapidly progress to life-threatening complications, including urosepsis. Early risk stratification is critical for timely intervention and improved patient outcomes. Although Hu’s nomogram has been proposed as a predictive tool for urosepsis, its external validation remains limited. This study aims to validate Hu’s nomogram in an independent cohort and identify novel clinical and imaging predictors of urosepsis. Methods: This retrospective cohort study included 341 patients diagnosed with ureteral calculi who underwent surgical intervention at a single institution between January 2019 and October 2023. Clinical, laboratory, and imaging data were collected. Univariate and multivariate logistic regression analyses were performed to identify independent predictors of urosepsis. The predictive accuracy of Hu’s nomogram was evaluated using receiver operating characteristic curve analysis. Results: Among 341 patients, 66 (19.4%) developed urosepsis. Multivariate analysis identified female gender, corticosteroid use, lower platelet count, elevated C-reactive protein levels, positive urine white blood cell count, lower computed tomography attenuation values of calculi, and higher computed tomography attenuation values of hydronephrosis as independent predictors of urosepsis. Hu’s nomogram demonstrated a strong predictive performance (area under the curve: 0.761; 95% CI: 0.701–0.821), reaffirming its clinical utility for risk stratification. Conclusions: This study provides an external validation of Hu’s nomogram and identifies novel risk factors for urosepsis prediction, including corticosteroid use and imaging-based parameters. Incorporating these findings into clinical practice may enhance early risk stratification, facilitate timely interventions, and ultimately improve patient outcomes. Full article

Background: This study investigated the clinical features, underlying causes, and management of patients with spontaneous perirenal hemorrhage (Wunderlich syndrome; WS). Methods: We retrospectively reviewed the records of patients hospitalized for WS at a single tertiary center between 2011 and 2024. All patients were evaluated for non-traumatic perirenal hemorrhage identified on computed tomography (CT) in the emergency department. Clinical variables, including age, underlying diseases, symptoms, hemodynamic instability, and hospitalization course, were analyzed. Laboratory test results, as well as radiological and pathological findings, were reviewed. Results: The study included 46 events from 38 patients, with a median (IQR) follow-up period of 32 (4–82) months. The most common presenting symptom was flank pain, observed in 44 cases (95.7%). Renal lesions, including visible tumors, were detected in 25 cases (54.3%), while 13 cases (28.3%) exhibited perirenal hematoma without a distinct lesion. Among seven patients with hemodynamic instability (systolic blood pressure < 90 mmHg), one underwent emergency embolization, and four required emergency surgical exploration. Surgical intervention was performed in 13 cases (28.3%), all involving nephrectomy, while radiologic embolization was attempted in seven cases (15.2%), with one patient later requiring delayed nephrectomy. The final diagnosis revealed renal cell carcinoma in eight cases (six patients), angiomyolipoma in 11 cases (six patients), renal cysts in six cases, acquired cystic kidney disease in six cases, sarcoma in three cases, perivascular epithelioid cell tumor in one case, lymphoma in one case, and chronic pyelonephritis in four cases; no specific disease was identified in six cases. During follow-up, six patients died; four of these deaths were directly related to WS or its underlying etiologies. Conclusions: WS is a potentially life-threatening condition, with benign or malignant renal masses being the most common causes. Although the advancement of interventional techniques has led to an increasing number of cases being conservatively managed, the possibility of renal malignancy should always be considered. Full article

The growing problem of infections due to pathogens with antimicrobial resistance, especially Gram-negative bacteria, has led to the development of new β-lactam/β-lactamase inhibitor combination antibiotics. During the last 2 years from the writing of this article, cefepime/enmetazobactam, aztreonam/avibactam, and sulbactam/durlobactam were approved for use in clinical practice. Cefepime/enmetazobactam targets extended-spectrum β-lactamase (ESBL)-producing Pseudomonas aeruginosa and Enterobacterales. It is indicated for the treatment of patients with complicated urinary tract infections, including pyelonephritis, in Europe and the USA, and also for hospital-acquired pneumonia, ventilator-associated pneumonia, and bacteremia associated with those infections (only in Europe). The antimicrobial spectrum of aztreonam/avibactam includes carbapenem-resistant Enterobacterales. Aztreonam/avibactam is indicated for the treatment of adult patients who suffer from complicated intra-abdominal infections, complicated urinary tract infections including pyelonephritis, hospital-acquired pneumonia, and ventilator-associated pneumonia due to aerobic Gram-negative infections with limited therapeutic options. Sulbactam/durlobactam, a combination of 2 β-lactamase inhibitors, is indicated for the treatment of adult patients with hospital-acquired bacterial pneumonia and ventilator-associated bacterial pneumonia due to the Acinetobacter baumannii–calcoaceticus complex [including carbapenem-resistant Acinetobacter baumannii (CRAB) infections]. Full article

Background: Only a few published cases of primary adenocarcinoma of the upper urinary tract have been described in the literature. The aim of this systematic review was to collect all published cases of primary adenocarcinoma of the upper UT and identify prognostic factors and useful diagnostic modalities for their optimal treatment. Methods: Systematic research in the PubMed/Medline and Scopus databases concerning primary adenocarcinoma of the upper urinary tract was performed by two independent investigators. A total of 85 studies were included in the review. Results: In total, 84 patients were included, consisting of 54 males (64.29%) and 30 females (35.71%). Out of the available data, 24.71% reported a history of lithiasis, 16.47% episodes of pyelonephritis and 10.59% a history of hydronephrosis. Concerning histologic findings on excised tumors, 52.44% of neoplasms were mucinous, 19.51% tubulovilous, 18.29% papillary, 4.88% mixed mucinous–papillary and 4.88% poorly differentiated. Concerning anatomical origin, 62.34% of tumors were found in the renal pelvis, 22.08% in the ureter and 12.99% in both the renal pelvis and the ureter. Surgical treatment was the preferred therapeutic option and was performed in 96.39% of the included patients. In multivariable analysis, a statistically significant relationship was found between a clinical cure and ureter origin of the lesion (OR: 0.17, 95% CI: 0.00–0.22, p = 0.002), the presence of an abdominal mass (OR: 0.08, 95% CI: 0.01–0.63, p: 0.034) and a poorly differentiated histological type (OR: 0.02, 95% CI: 0.00–0.91). In multivariable time-to-event analysis, the male sex (HR: 0.12, 95% CI: 0.02–1.01, p: 0.019) and poorly differentiated histological type (HR: 91.06, 95% CI: 7.31–1134.32, p: 0.002) had statistically significant impacts on overall survival. Conclusions: Selection of the optimal surgical management, via either nephrectomy or nephroureterectomy, depends on the origin of the primary lesion and represents the mainstay of treatment. A suspicion from the urologist is needed for the identification and optimal treatment of these rare tumors. Full article

Background/Objectives: The management of urinary tract infections (UTIs) has become an increasingly challenging medical intervention. This study explores whether adoption of a precision medicine model could improve the management of acute uncomplicated pyelonephritis (uAPN) or complicated UTIs (cUTIs) compared with the standard of care approach, in hospitalized patients. Methods: From January 2022 to March 2024, all patients affected by uAPN or cUTIs and attending our urological institution were randomized to receive the following: antibiotic treatment according to guidelines and recommendations (standard of care group) or antibiotic treatment according to the precision medical model (intervention group). The main outcome measures were the rates of clinical success and the length of hospitalization. The time until switching to oral treatment was regarded as a secondary outcome measure. Results: Eighty-three patients were enrolled in the standard of care group, while seventy-nine patients were enrolled in the intervention group. While the overall clinical success rate was similar in the two groups (75 vs. 72; p = 0.97), a statistically significant difference was observed between the two groups in terms of length of hospitalization (8 days vs. 5 days; p = 0.03) and time to switch to oral treatment (96 h vs. 72 h; p = 0.04). A statistically significant difference was found between the two groups regarding the need to change antimicrobial therapy during hospitalization [12 out of 80 vs. 6 out of 77; p = 0.04]. Conclusions: Adoption of the precision medicine model appears as a valuable means to improve the management of patients with uAPN and cUTIs. By reducing the period of hospitalization and the time to switch to oral treatment, the precision medicine model also improves antimicrobial stewardship in the management of UTIs. Full article

Urinary tract infections (UTIs) represent a prevalent health concern among the female population, with anatomical and physiological determinants such as a shorter urethra and its proximity to the rectum augmenting vulnerability. The presence of Escherichia coli and various other pathogens plays a significant role in the etiology of these infections, which can be aggravated by sexual intercourse and disturbances to the vaginal microbiome. The physiological alterations associated with pregnancy further elevate the likelihood of UTIs, with untreated cases potentially leading to severe complications such as pyelonephritis, preterm labor, and stillbirth. Furthermore, postmenopausal women encounter an augmented risk of UTIs attributable to estrogen deficiency and vaginal atrophy, as well as conditions including pelvic organ prolapse (POP) and urinary incontinence (UI), which hinder optimal bladder functionality. The aforementioned factors, in conjunction with the rising prevalence of cesarean deliveries and catheterization, complicate the management of UTIs. While precise diagnosis is paramount, it remains a formidable challenge, notwithstanding advancements in molecular diagnostic techniques. Management strategies encompass antibiotic-sparing therapies; however, the increasing incidence of multidrug resistance represents an alarming trend. Diverse guidelines from various medical specialties endeavor to standardize treatment approaches, yet significant inconsistencies continue to exist. This study systematically appraises the extant guidelines, evaluating the quality of evidence while identifying areas of agreement and discord to supply practitioners with effective strategies for UTI management. Full article

Background/Objectives: First-generation cephalosporins are used in some countries, primarily in Latin America and other low-resource regions, as a first-line or alternative empirical treatment for patients with acute pyelonephritis (AP). This study aimed to evaluate the impact of inappropriate empirical therapy with cefazolin on the clinical outcomes of adult patients with community-acquired AP caused by resistant Enterobacterales, requiring hospitalization in two tertiary hospitals in Bogotá. Methods: This retrospective cohort study included hospitalized patients with community-acquired AP caused by Enterobacterales who received initial treatment with cefazolin at two tertiary-level institutions in Colombia (January 2013–2020). Inappropriate treatment was defined as a resistant isolate to cefazolin in the urine culture. Outcomes assessed included hospital stay, hospital mortality, and recurrence. Results: A total of 1031 patients were admitted, among whom 218 (21.1%) received inappropriate treatment. The mean length of stay was 4.8 (5.1) days, 996 (96.6%) survived to discharge, and 113 (11.0%) were admitted for a recurrence of AP. Inappropriate treatment had no impact on hospital stay (RRA 0.98, 95% CI 0.84–1.15) or hospital mortality (OR 1.02, 95% CI 0.47–2.19), although it was associated with a greater risk of admission because of recurrence (OR 3.7, 95% CI 2.4–5.8). Conclusions: We found that inadequate empirical treatment with cefazolin in adult patients with community-acquired acute pyelonephritis does not appear to change the length of hospital stay or in-hospital mortality in patients but is associated with an increased risk of readmission due to recurrence; this might favor the use of empirical narrow-spectrum antibiotics but with strategies that allow monitoring or early detection of microbiological non-eradication to prevent recurrence. Full article