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Antibody-coated bacteria in urine of patients with ileal conduit urinary diversion
ANTIBODY-COATED PATIENTS
BACTERIA
IN URINE OF
WITH ILEAL CONDUIT
URINARY DIVERSION*
JEFFREY
R. WOODSIDE,
WILLIAM
P. REED,
JOHN
D. KIKER,
THOMAS
M.D.
M.D.
B.S.
A. BORDEN,
M.D.
From the Division of Urology, University of New Mexico School of Medicine, and the Department of Medicine, Albuquerque Veterans Administration Hospital, Albuquerque, New Mexico
ABSTRACT - The antibody-coated bacteria (ACB) test is a helpful adjunct fn- differentiating pyelonephritis from cystitis in the intact urinary tract, particularly in female patients. This test was used in patients with ileal conduits and infected urine in an attempt to determine whether bacilluria was of renal or conduit origin. Every patient with infected conduit urine had a positive ACB test even though no patient had clinical stigmas of acute pyelonephritis. In patients with ileal conduits, the ACB test cannot be used alone as an indicator that bacilluria is a cause of symptoms or renal damage.
A recently introduced technique, the antibodycoated bacteria (ACB) test, has been used to differentiate renal from bladder infection in patients with intact urinary tracts.‘~~ The test is based on the fact that parenchymal infection (pyelonephritis) elicits an immunologic response and results in coating of the invading bacteria with immunoglobulin. Nonparenchymal infections (cystitis) generate no such antibody response. When fluorescent antibodies to human immunoglobulin are allowed to react with bacteria in the urinary sediment from patients with bacteriuria, any bacteria coated with human immunoglobulin will become fluorescent. Bacterial fluorescence is interpreted as a positive ACB test and implies pyelonephritis in females, and pyelonephritis or prostatitis in males.
Many patients with ileal conduits have infected urine. Pyelonephritis with subsequent renal deterioration occurs in some. Unfortunately, there is no clinically available method for separating renal bacteriuria and conduit contamination. The ACB test has been used in this institution in an attempt to determine if renal infection exists in ileal conduit patients with obscure fever. If positive, such patients have generally been treated for acute pyelonephritis. We were concerned that such treatment was based on a test of unknown validity in these patients. Therefore, this article describes the results of a study designed to determine if the ACB test can differentiate bacteriuria of renal origin from that of conduit contamination. Material
*This study was supported in part by a grant from the Kidney Foundation of New Mexico, Inc.
472
and Methods
Fifteen patients with ileal conduits were studied ranging in age from seven to thirty-
UROLOGY
/
MAY 1978
/
VOLUME XI, NUMBER 5
three years. Urine specimens were collected after washing the stoma1 area thoroughly. A sterile double catheter technique, performed by inserting a 5 F infant feeding tube inside a 14 F Robinson catheter placed in the conduit, was used to obtain urine. Routine culture and colony count were done. If greater than lo5 organisms per milliliter were grown from the sample, the sediment was examined for antibody-coated bacteria by the method of Thomas, Shelokov, and Forland.’ Preoperative and current intravenous pyelograms were compared in all patients with positive urine cultures. Each kidney was considered separately as one renal unit. Results Nine of the 15 patients studied had positive urine cultures (> lo5 organisms per milliliter). All 9 of these patients had positive ACB tests. No patient had symptoms suggesting infection. Three of the eighteen renal units analyzed with intravenous pyelograms had radiographic changes of pyelonephritis. Comment
/
MAY 1978
/
VOLUME
2211 Lomas Boulevard NE Albuquerque, New Mexico 87131 (DR. WOODSIDE) ACKNOWLEDGMENT.
Urine obtained from an ileal conduit frequently contains greater than lo5 organisms per milliliter. 1,3,4 Since many patients with conduits suffer from chronic pyelonephritis, it is important to know whether this bacteriuria represents active renal infection or conduit contamination. This study attempted to determine the accuracy of the ACB test for localizing the origin of bacteriuria in patients with ileal conduits. No patient had symptoms of acute pyelonephritis, and only three of eighteen renal units had pyelographic evidence of pyelonephritis. Nonetheless, the ACB test was invariably positive when the conduit urine contained greater than lo5 organisms per milliliter.
UROLOGY
These results do not exclude the possibility that each of these patients had a renal focus of infection nor do they preclude conduit contributed immunoglobulin. One may conclude that a positive ACB test alone does not constitute valid grounds for treating an ileal conduit patient for acute pyelonephritis, nor does it appear to help in their management in any way. The ACB test described herein is a gross screening test. It does not differentiate between various types of immunoglobulin nor is it quantitative. Other studies have suggested that immunoglobulins produced by the kidney and intestine are both qualitatively and quantitatively different. 5s It is conceivable that selective immunofluorescent antibody tests and quantitative immunoglobulin excretion determinations might resolve the question of the origin of ileal conduit bacteriuria. Such studies are currently in progress and will be the subject of a subsequent report.
XI, NUMBER
5
edge the technical
The authors gratefully assistance of Mr. Roy Kaiwa.
acknowl-
References 1. Thomas VL, Forland M, and Shelokov A: Antibody-coated bacteria in urinary tract infection, Kid. Int. 8: 520 (1975). 2. Thomas V, Shelokov A, and Forland M: Antibodv-coated bacteria in the urine and the site of urinary tract infection, N. Engl. 1. Med. 296: 588 (1974). 5 Spence B, Ireland GW, and Cass AS: Bacteriuria in intestinal loop urinary diversion in children, J. Ural. 166: 786 (1971). ureterostomy in children: indica4. Smith ED: Ileo-cutaneous tions and results, Aust. N. 2. J. Surg. 33: 169 (1964). 5. Plant AC, and Keonil P: Immunoglobulins in human small intestinal fluid, Gastroenterology 56: 522 (1969). 6. Hanson LA, et al: Studies on the immunoglobulins of children with urinary tract infections, in Delbert H, et al., Eds.: The Secretory Immunologic Systems, Washington, D.C., U.S. Government Printing O&e, 1969, pp. 367-383.
473
BACTERIA
IN URINE OF
WITH ILEAL CONDUIT
URINARY DIVERSION*
JEFFREY
R. WOODSIDE,
WILLIAM
P. REED,
JOHN
D. KIKER,
THOMAS
M.D.
M.D.
B.S.
A. BORDEN,
M.D.
From the Division of Urology, University of New Mexico School of Medicine, and the Department of Medicine, Albuquerque Veterans Administration Hospital, Albuquerque, New Mexico
ABSTRACT - The antibody-coated bacteria (ACB) test is a helpful adjunct fn- differentiating pyelonephritis from cystitis in the intact urinary tract, particularly in female patients. This test was used in patients with ileal conduits and infected urine in an attempt to determine whether bacilluria was of renal or conduit origin. Every patient with infected conduit urine had a positive ACB test even though no patient had clinical stigmas of acute pyelonephritis. In patients with ileal conduits, the ACB test cannot be used alone as an indicator that bacilluria is a cause of symptoms or renal damage.
A recently introduced technique, the antibodycoated bacteria (ACB) test, has been used to differentiate renal from bladder infection in patients with intact urinary tracts.‘~~ The test is based on the fact that parenchymal infection (pyelonephritis) elicits an immunologic response and results in coating of the invading bacteria with immunoglobulin. Nonparenchymal infections (cystitis) generate no such antibody response. When fluorescent antibodies to human immunoglobulin are allowed to react with bacteria in the urinary sediment from patients with bacteriuria, any bacteria coated with human immunoglobulin will become fluorescent. Bacterial fluorescence is interpreted as a positive ACB test and implies pyelonephritis in females, and pyelonephritis or prostatitis in males.
Many patients with ileal conduits have infected urine. Pyelonephritis with subsequent renal deterioration occurs in some. Unfortunately, there is no clinically available method for separating renal bacteriuria and conduit contamination. The ACB test has been used in this institution in an attempt to determine if renal infection exists in ileal conduit patients with obscure fever. If positive, such patients have generally been treated for acute pyelonephritis. We were concerned that such treatment was based on a test of unknown validity in these patients. Therefore, this article describes the results of a study designed to determine if the ACB test can differentiate bacteriuria of renal origin from that of conduit contamination. Material
*This study was supported in part by a grant from the Kidney Foundation of New Mexico, Inc.
472
and Methods
Fifteen patients with ileal conduits were studied ranging in age from seven to thirty-
UROLOGY
/
MAY 1978
/
VOLUME XI, NUMBER 5
three years. Urine specimens were collected after washing the stoma1 area thoroughly. A sterile double catheter technique, performed by inserting a 5 F infant feeding tube inside a 14 F Robinson catheter placed in the conduit, was used to obtain urine. Routine culture and colony count were done. If greater than lo5 organisms per milliliter were grown from the sample, the sediment was examined for antibody-coated bacteria by the method of Thomas, Shelokov, and Forland.’ Preoperative and current intravenous pyelograms were compared in all patients with positive urine cultures. Each kidney was considered separately as one renal unit. Results Nine of the 15 patients studied had positive urine cultures (> lo5 organisms per milliliter). All 9 of these patients had positive ACB tests. No patient had symptoms suggesting infection. Three of the eighteen renal units analyzed with intravenous pyelograms had radiographic changes of pyelonephritis. Comment
/
MAY 1978
/
VOLUME
2211 Lomas Boulevard NE Albuquerque, New Mexico 87131 (DR. WOODSIDE) ACKNOWLEDGMENT.
Urine obtained from an ileal conduit frequently contains greater than lo5 organisms per milliliter. 1,3,4 Since many patients with conduits suffer from chronic pyelonephritis, it is important to know whether this bacteriuria represents active renal infection or conduit contamination. This study attempted to determine the accuracy of the ACB test for localizing the origin of bacteriuria in patients with ileal conduits. No patient had symptoms of acute pyelonephritis, and only three of eighteen renal units had pyelographic evidence of pyelonephritis. Nonetheless, the ACB test was invariably positive when the conduit urine contained greater than lo5 organisms per milliliter.
UROLOGY
These results do not exclude the possibility that each of these patients had a renal focus of infection nor do they preclude conduit contributed immunoglobulin. One may conclude that a positive ACB test alone does not constitute valid grounds for treating an ileal conduit patient for acute pyelonephritis, nor does it appear to help in their management in any way. The ACB test described herein is a gross screening test. It does not differentiate between various types of immunoglobulin nor is it quantitative. Other studies have suggested that immunoglobulins produced by the kidney and intestine are both qualitatively and quantitatively different. 5s It is conceivable that selective immunofluorescent antibody tests and quantitative immunoglobulin excretion determinations might resolve the question of the origin of ileal conduit bacteriuria. Such studies are currently in progress and will be the subject of a subsequent report.
XI, NUMBER
5
edge the technical
The authors gratefully assistance of Mr. Roy Kaiwa.
acknowl-
References 1. Thomas VL, Forland M, and Shelokov A: Antibody-coated bacteria in urinary tract infection, Kid. Int. 8: 520 (1975). 2. Thomas V, Shelokov A, and Forland M: Antibodv-coated bacteria in the urine and the site of urinary tract infection, N. Engl. 1. Med. 296: 588 (1974). 5 Spence B, Ireland GW, and Cass AS: Bacteriuria in intestinal loop urinary diversion in children, J. Ural. 166: 786 (1971). ureterostomy in children: indica4. Smith ED: Ileo-cutaneous tions and results, Aust. N. 2. J. Surg. 33: 169 (1964). 5. Plant AC, and Keonil P: Immunoglobulins in human small intestinal fluid, Gastroenterology 56: 522 (1969). 6. Hanson LA, et al: Studies on the immunoglobulins of children with urinary tract infections, in Delbert H, et al., Eds.: The Secretory Immunologic Systems, Washington, D.C., U.S. Government Printing O&e, 1969, pp. 367-383.
473