Bacteremia in Young Urban Women Admitted with Pyelonephritis

Bacteremia in Young Urban Women Admitted with Pyelonephritis WALLY R. SMITH, MD,* DONNA K. McCLISH, PHD,* ROY M. POSES, MD,* ANDY G. PINSON, MD,* STEPHEN T. MILLER, MD,t LORETTA BOBO-MOSELEY, MD,t ROBERT E. MORRISON, MD,t DANIEL J. LANCASTER, MDt

ABSTRACT: The objective of this study was to determine the rate of bacteremia in young women admitted to the hospital with presumed pyelonephritis and compare it with other published rates. The study design was a retrospective, structured chart review and a review of published reports of bacteremic pyelonephritis. An urban county teaching hospital provided the setting for the study. The patients were nonpregnant women (n = 98) 44 years of age or younger who were without bladder dysfunction and who had not been admitted to an intensive care unit. Further criteria for participation included discharge with the diagnosis of acute pyelonephritis. Blood cultures were ordered for 69 women; the results of 64 were noted in the chart. Twentythree women (35.9% of those cultured; 23.4% of all patients) were diagnosed with bacteremia. In patients for whom blood culture results were obtained, trends developed between those patients with bacteremia and those with complicated pyelonephritis, defined as a known or newly discovered genitourinary abnormality or a risk factor (P = 0.044), those who were black (P = .044), those with higher pulses on admission (P = .050), those with more white blood cells per high-powered field after urinalysis (P = 0.007), and those whose fever lasted longer (P = 0.033). Blood culture results were positive in two patients whose urine cultures were negative. This comparatively high bacteremia rate supports routine ordering of blood cultures for urban women suspected of having pyelonephritis. KEY INDEXING TERMS: Pyelonephritis; Women; Urinary tract

From the *Medical College of Virginia, Richmond, Virginia and the tUniversity of Tennessee, Memphis, Tennessee. Submitted November 16, 1994; accepted in revised form July 22,1996. Correspondence: Wally R. Smith, MD, 1200 East Broad Street, Room 7-015, Box 980306, Richmond, VA 23298.

50

infection; Bacteremia. [Am J Med Sci 1997; 313(1):50-57.]

O

ne review estimates that there are approximately 250,000 women diagnosed with acut.e pyelonephritis yearly in the United States. l PhYSIcians often admit patients diagnosed with presumed acute pyelonephritis to administer parenteral antibiotics and fluids. They also test these patients for bacteremia. Because there is no compelling evidence that supports the alteration of therapy for pyelonephritis when the patient has bacteremia,2 awareness of bacteremia has prompted closer observation for signs of concomitant septic shock and other complications that would require adjunctive therapy, would lengthen the patient's hospital stay, or would result in death. 3 There is evidence that the detection and treatment of gram-negative bacteremia could decrease the incidence of shock and enhance survival. 4 Previous studies supported the notion that bacteremic pyelonephritis occurred less commonly in younger women,5-l5 even when it was unasso~iated with a radiographic genitourinary abnormalIty or recent instrumentation. l6 However, a chart-review study of un selected hospital patients showed a fairly high bacteremia rate in women younger than 50P Few studies selected urban or minority populations. l8 The authors investigated whether young women admitted to an urban teaching hospital with presumed acute pyelonephritis were diagnosed with bacteremia more often than was reported and they studied the factors associated witp the occurrence of bacteremia in these patients. Methods Setting and Patient Assignment. Patients were se-

lected from an urban, university-affiliated county hospital. Before searching for medical records, several inclusion and exclusion criteria were deterJanuary 1997 Volume 313 Number I

Smith et 01

mined. Use of the discharge database in the medical records department was requested for the purpose of identification of patients who were eligible to participate in the study according to the criteria. Women of age 16 to 44 years who were discharged from January 1981 through December 1985 and who were diagnosed with the version 9 code for acute pyelonephritis from the International Classification of Diseases were included. Women who were found to have an obstruction during or after the index visit were not excluded. Using these criteria, a total of98 eligible patients were identified. After chart identification, no other patients were excluded. Attending physicians were from the subspecialty and general divisions of internal medicine, and house staff and doctors rotated within the general internal medicine services. Data Collection. Patient demographic characteristics, such as the chronology and symptomatology of the illness, medical history, and any physical findings, were recorded. Urine and blood bacteriologic test results, other pertinent laboratory results, and radiographic results also were recorded. Literature Review. The literature was reviewed for comparison of the bacteremia rates reported herein with those from previous studies of nonpregnant women with pyelonephritis. To find relevant articles, the MeSH term "explode pyelonephritis" was cross-referenced with either "explode epidemiology" or "explode bacteremia." The search for articles was limited to those published in English from 19661994. The resultant citations were searched by one author (WRS) and either read for relevance or discarded, depending on their topic and the inclusion criteria for subjects. The bibliographies of relevant articles were searched for other relevant articles. Definitions. For the chart review, five traditionally accepted symptoms or signs of urinary tract infection or pyelonephritis were defined: dysuria, frequency or urgency; fever; chills; nausea or vomiting; and flank pain or costovertebral angle tenderness. To define complicated pyelonephritis for purposes of our study, obstructive pyelonephritis was defined as that which is associated with a known or newly discovered genitourinary abnormality. A risk factor for pyelonephritis was defined as a disease or clinical factor cited in the literature as related, or plausibly related, to pyelonephritis. Finally, complicated pyelonephritis was defined as either obstructive or associated with a risk factor. The bacteremia rate in this and other studies reviewed was calculated using the ratio of positive culture episodes to total culture episodes. A culture episode was defined as one or more blood culture results reported during an admission; positive was defined as the growth of a urinary tract pathogen in any blood culture. We excluded those patients who did not receive cultures or whose culture results were THE AMERICAN JOURNAL OF THE MEDICAL SCIENCES

not listed in the chart. Sixty-four patients remained as the denominator for bacteremia rate calculations and bacteremia associations. Analysis. After descriptive analyses that included demographic and potential risk factors were conducted, a bacteremia rate for this study and the bacteremia rates for the other studies reviewed were calculated using the identical formula of positive culture results to total culture episodes. Calculations for other studies were based on their reported bacteremia and culture rates. Associations between demographic or potential risk factors and bacteremia were determined. For categoric variables, chi-square tests were performed. For ordinal variables, Wilcoxon rank sums were calculated. For continuous variables, t-tests were performed. Results DemographiCS, History and Physical, and Bacteriology. The patients ranged in age from 16 years to 44

years (mean, 25.2 years). Table 1 illustrates that 65 (66.3%) of 98 patients had complicated pyelonephritis and that 30 (30.6%) of98 patients had obstructive pyelonephritis, some with both renal and urologic sources of obstruction. In addition, 53 (54%) of 98 patients met the criteria for complicated pyelonephritis because they had the risk factors for pyelonephritis as defined. Some of these patients also had obstructive pyelonephritis. At least one traditionally accepted symptom or sign of urinary tract infection or pyelonephritis manifested itself in all the patients. Only 3% of the patients had only one of these symptoms, 5% had two signs, 10% had three signs, 42% had four signs, and 40% had five signs or more. The results of the urine and blood bacteriologic analysis are shown in Table 2. Although > 100,000 organisms/mL grew in most of the patients' urine, no organisms grew in 12% of the patients' urine, yet they were discharged with the diagnosis of pyelonephritis. For a few patients, no urine bacteriologic data were recorded in the chart. Of 12 women whose urine culture results were negative, one experienced only flank pain and tenderness. The other 11 patients were diagnosed with pyelonephritis because of flank pain and tenderness and a mild fever (>99.5° F) that responded to antibiotics (range, 1 day to 6 days). Other findings in these 11 patients included two instances of Escherichia coli (E. coli) bacteremia, four previous diagnoses of pyelonephritis (one ofthese required urologic surgery), and two previous urinary tract infections. Blood cultures were ordered, but the results were negative, in four of the patients. The organisms cultured from the patients' urine are usually seen in pyelonephritis. E. coli predominated; only one patient had more than one organism cultured from her urine. Blood culture results from 51

Bacteremia

Table 1. Descriptive Characteristics for Sample Blood Culture Results Characteristic Demographic Age in years, mean ± SD Race Black White Complicated pyelonephritis Obstructive pyelonephritis* Known genitourinary abnormality Known underlying intrinsic renal disease Known urologic abnormality Newly discovered or additional genitourinary abnormality Known risk factor(s) Diabetes Hypertension Neurologic disease (other than spinal cord) Congestive heart failure Gout Sickle cell disease Hyperparathyroidism, hypercalcuria, hypercalcemia Frequent analgesic use Current oral contraceptive use Intravenous drug abuse Other comorbidityt History and physical exam Days ill prior to admission (mean ± SD) Previous urinary tract infection Previous pyelonephritis Dysuria (frequency or urgency) Fever Chills:j: Nausea or vomiting Flank pain and/or CVA tenderness Laboratory results, mean ± SD BUN (mg/dL)§ Creatinine (mg/dL)~ White blood count (103 ) Length of stay (days, mean ± SD)

Present (n = 64) No. (%)

Absent (n = 34) No. (%)

Total (n = 98) No. (%)

25.2 ± 6.8

25.4 ± 7.1

25.2 ± 6.8

46 (72) 18 (28) 46 (72) 21 (33) 8 (12) 4 (6) 6 (9)

29 5 19 9 5 3 3

(85) (15) (56) (26) (15) (9) (9)

75 (77) 23 (23) 65 (66) 30 (31) 13 (13) 7 (7) 9 (9)

17 (26) 38 (59) 10 (16) 7 (11) 1 (2) 1 (2) 0(0) 0(0)

9 (26) 15 (44) 3 (9) 3 (9) 2 (6) 0(0) 0(0) 1 (3)

26 (26) 53 (54) 13 (13) 10 (10) 3 (3) 1(1) 0(0) 1(1)

1 (3) 9 (26) 3 (9) 0(0) 1 (3)

4 (4) 18 (18) 12 (12) 2 (2) 6 (6)

3 9 9 2 5

(5) (14) (14) (3) (8)

5.8 ± 4.9 35 (55) 19 (30) 50 (78) 60 (94) 55 (86) 41 (64) 64 (100)

4.9 17 8 25 29 24 23 34

± ± ± ±

9.7 1.1 14.3 5.8

10.9 1.2 15.5 5.8

13.8 0.9 6.0 2.8

± 5.2 (50) (24) (78) (88) (71) (68) (100) ± ± ± ±

3.8 0.4 5.6 3.3

5.5 52 27 75 89 79 64 98 10.5 1.1 15.1 5.8

± 5.0 (53) (28) (78) (92) (81) (65) (100) ± ± ± ±

11.4 0.7 5.9 3.0

* Categories of obstruction are not mutually exclusive. t Other comorbidies include vaginitis, pelvic inflammatory disease, GU instrumentation. :j:P = .067. § n = 61, blood culture present, n = 31, blood culture absent. ~ n = 55, blood culture present, n = 25, blood culture absent. BUN = blood urea nitrogen.

64 (65.3%) of the patients studied were noted in the chart. Twenty-three (35.9%) ofthe results ofthe cultures from the 64 patients were positive and indicative of bacteremia. There were no significant differences among the demographic characteristics, the rates of obstructive and complicated pyelonephritis, the prevalence of risk factors, and the physical findings in patients whose blood culture results were either on the chart or not (Table 1). Overall, the results of the blood cultures of 23.5% of the women eligible for this study were positive. All but a few of

52

these blood cultures grew E. coli. The blood cultures with positive results grew pathogens that matched the urine pathogen in all but two patients. The urine culture results of these two exceptions were negative, but the results of the blood cultures were positive for E. coli. No patients were readmitted to the index hospital within 6 weeks of discharge. The outpatient followup rate was 21%. Only two readmissions occurred within 3 years of discharge. Repeat emergency room visits were not studied. January 1997 Volume 313 Number I

Smith et al

Table 2. Bacteriologic Results (n

Urine colony counts No. of Organisms >100,000 >10,000 but <100,000 >1,000 but <10,000 No growth Data lost Organisms cultured Urine E. coli Klebsiella Proteus Enterococcus Staph Species Mixed Contaminated (nl. flora) No growth Data lost Blood E. coli Staph species Other Results lost No growth No culture

=

98)

No.

%

66 8 2 12 10

67.4 8.2 2.0 12.2 10.2

64 2 1 1 2 1 4 12 11

65.5 2.0 1.0 1.0 2.0 1.0 4.1 12.2 11.2

20 1 2 5 41 29

20.4 1.0 2.0 5.2 41.8 29.6

Associations With Bacteremia. The trends toward an association with bacteremia are shown in Table 3. Patients with bacteremia had more pyuria than those with negative culture results. Patients with bacteremia tended to have a potential risk factor, complicated pyelonephritis, or a shorter symptom interval before admission. They also tended to have higher initial pulses and to remain febrile longer while in the hospital. In an analysis that assumed uncultured patients were sterile, the associations seen with bacteremia were the same. To determine whether the bacteremia rates in the study held for the less ill versus the more ill patients of the sample, the bacteremia rate for the patients whose blood culture results were reported were calculated. Women who met the

criteria for obstructive pyelonephritis were compared with those who did not. A bacteremia rate of 47.6% (10 of 21 patients) was found in women with obstructive pyelonephritis versus a rate of30.2% (13 of 43 patients) that was found in women with nonobstructive pyelonephritis (P = 0.17). Of the 43 women with nonobstructive pyelonephritis, 25 women who had at least one risk factor for pyelonephritis were compared with the 18 patients who had uncomplicated pyelonephritis (no obstruction, no risk factors). A bacteremia rate of 16.7% (3 of 18 patients) was found among women with no risk factors versus a rate of 40% (10 of25 patients) that was found among those with at least one risk factor (P = 0.10). Bacteremia Rate Comparisons. Using the search criteria given in the methods section, 262 articles were found. Studies of presumed or proven pyelonephritis that reported bacteremia prevalence rates were selected. 5 - 13 ,15-18 All irrelevant studies were excluded (Table 4). Each comparison study reviewed included elderly women and men. The current bacteremia rate was higher than all but three of the reports reviewed. 8 ,13,16 Two studies that were reviewed included a subanalysis by age. The first demonstrated no bacteremia in women 16 years to 44 years of age (the age range analogous to the current study) but demonstrated a 48% bacteremia rate in women 65 to 96. 16 The second study demonstrated a 27% bacteremia rate in women who were either younger than 50 or 50 years or older. 17 Discussion

Chart review revealed a 36% bacteremia rate in women younger than 45 who had nonobstructive pyelonephritis and who underwent blood cultures. Two of the 23 positive results from the blood cultures occurred in women with negative results of urine cultures. Selection Criteria and Bacteremia Rates. The patient group consisted of those admitted to a hospital from a larger pool of patients with suspected pyelonephritis who were first seen in an emergency department. Patients probably were admitted because of vom-

Table 3. Trends of Association With Bacteremia Variable

Bacteremic (n

Black (No., %) Complicated pyelonephritis (No., %) Obstructive pyelonephritis (No., %) Risk factor present (No., %) Median WBCslHPF (No., %) Days ill prior to admission * Pulse on admission* Hospital days febrile*

20 (87) 20 (87) 10 (43) 17 (74) 250 3.9:!:: 2.1 104:!:: 14 3.6 :!:: 1.4

=

23)

Nonbacteremic (n 26 (63) 26 (63) 11 (27) 21 (51) 100 6.9:!:: 5.7 96 :!:: 13 2.8 :!:: 1.4

=

41)

Total (n = 64)

P

46 (72) 46 (72) 21 (33) 38 (59) 100 5.8:!:: 4.9 99 :!:: 14 3.1 :!:: 1.4

.044 .044 .173 .076 .007 .056 .050 .033

* Values are expressed as mean:!:: SD. HPF = high power field; WBe = white blood count. THE AMERICAN JOURNAL OF THE MEDICAL SCIENCES

53

~

CT

3

c

z

(,>

~

~

§-

<

-< :g ....

Q :::I C Q

'-

~

0/100

18-82

9

18-96

15-66

65-90

18-44*

46-64 65-96* >54 19-76

66 6 5615

188

57 35 '3

120'2 20 '6

5 '6 34 '6 9 '6 35"

:2:50 52:+: 23 0/100 0/100

0/100

0/100 0/100 0/100 20/80

0/100 0/100

0/100 34/66

0/100

0/100 52/48

0/100

20/80

<10 54

<10

o

o

21

27

]

Inpatient; :2:7 WBCIHPF or :2:10,000 CFU/mL; :2:37.8 C

Above; Known calculi; Fistula Inpatient; Internal medicine ward; Suspected nonobstructive; No pregnancy; No allergy contrast dye; :2:100,000 cfulmL; No recent drug therapy; Informed consent Inpatient; discharge diagnosis pyelonephritis; UTI or gram negative bacteremia and UTI

Inpatient; Fever; Voiding signs; CVAT; Leukocytosis; Pyuria; > 100,000 cfulmL Enterobacteriaceae; No indwelling catheter

84 100

27 29

27

17

100 92

48

o

19 61

33

20

11

19

22

20

(%)

=

Bacteremic

97

85

56 89

100

45

100

58

49

76

(%)

Inpatient; Urgent admission; Doctor-presumed pyelonephritis; No recent drug therapy or transplant; Intact collecting system Outpatient; Inpatient; :2:3 signs or symptoms (dysurea, flank pain, nausea/vomiting; CVA tenderness, Leukocytosis; Fever; Pyuria or :2:10,000 cfulmL Outpatient; Inpatient; Age :2:15; Flank pain or CVAT; Fever >38 C; No parenteral drug therapy; No pregnancy, No Indwelling catheter, No drug hypersensitivity, Cr Cl >30 cc/min, <5 X nl. LFT's, No theophylline, No drug therapy within 7 d Inpatient; :2:18 yrs; Suspected pyelonephritis; IV drug therapy; CVAT or pain; pyuria or :2:10,000 cfulmL; No drug hypersensitivity, No pregnancy, or breast feeding; No anatomic or functional GU abnormality; No concomitant drug therapy or within 48 h; No GU instrumentation Inpatient; >100,000 cfulmL; Fever; Voiding signs; CVAT Inpatient; Gentomycin-resitant Klebsiella; > 100,000 cfulmL; > 12 X 106 leukocyteslL >12 yrs; Fever; CVAT; Pyuria, >100,000 cfulmL; E. coli, No pregnancy; No drug hypersensitivity, No drug therapy within 72 h Community-acquired pyelonephritis; Drug therapy w/study drug Inpatient; Elderly; No catheter; Fever; Constitutional signs; > 100,000 cfulmL; No other infection; Cancer not cause; No Prostatitis; No Epididymitis

Cultured

(%)

Inclusion Criteria

Black

CVA = costovertebral angle; CVAT = costovertebral angle tenderness; au = genitourinary; HPF = high-power field; ICU = intensive care unit; IV = intravenous; LFT liver function tests; UTI = urinary tract infection; WBC = white blood count.

123 '7 28 '8

72'7

<50

18-89

85 7

8

16-87

140 '0

194

4/96

16-86

(%)

185 5

M/F

Age (range in yrs)

n

Table 4. Bacteremia Rate Comparisons

o·

3

CD

CD

gJ

c o

Smith et al

iting, which precluded safe administration of oral therapy, or because they had other toxic symptoms. Undoubtedly, these selection criteria biased the study toward including more severely ill patients; thus the rate of bacteremia was increased. However, some patients with obvious obstruction or instrumentation (indwelling Foley catheters, bladder atony, and pregnancy) were excluded. Patients admitted to intensive care units also were excluded. Probably because of these exclusion factors the bacteremia rate was decreased. Unlike all previous studies reviewed that reported high bacteremic pyelonephritis rates, older women and men were excluded (Table 4).

Among women whose blood culture results were reported, the bacteremia rate for those with nonobstructive pyelonephritis tended to be lower than the rate for those with obstructive pyelonephritis. Similarly, among women with nonobstructive pyelonephritis there was a trend toward a lower bacteremia rate for women without a risk factor versus those with at least one risk factor. Thus, the bacteremia rate appears sensitive to comorbid and complicating factors of the infection. Our sample differed from others because it consisted of urban patients who were predominately black. Indeed, a weak relationship was found between race and bacteremia. It is possible that this relationship and the overall higher rate of bacteremia might result from genetically based host defense differences resident in the urinary tract epithelia. 19 ,2o Other factors in this study potentially compromised the host defenses of the patients (Table 1). Note that the obstructive pyelonephritis rate (30.6%), is comparable to Grover et al's5 chart review. Recent case-control studies have focused on better elucidating host defense mechanisms and bacterial virulence mechanisms for bacteremic pyelonephritis. This evidence suggests that the P-fimbriae virulence factor, when present, contributes to bacteremill, but it also suggests that in patients with non-P-fimbriated infection, host factors compromise immunity and contribute to bacteremia pyelonephritis. 21 ,22 It was not determined which virulence factors were present on strains isolated in this study. However, there is a precedent for considering the predilection of P-fimbriated strains for a specific race. Differences in the rates of chlamydial infection between blacks and whites have been recently traced to specific serovars of Chlamydia trachoma tis (C. trachoma tis) associated with particular races. 23 Other Findings. A trend developed toward an association of a shorter symptom interval with bacteremia (Table 3). In contrast, some have suggested that a longer duration of symptoms is associated more often with bacteremia. A few studies have demonstrated that a longer symptom interval is associated with antibody-coated bacteria24 (a laboratory finding THE AMERICAN JOURNAL OF THE MEDICAL SCIENCES

that signifies tissue invasion that was used to distinguish upper from lower urinary tract infection). Caution is advised when using the findings to support reliance on symptom interval as a predictor of bacteremia because this measurement may be confounded by the patients' willingness to seek care. Despite a poor outpatient follow-up rate (21%) and a 23% overall bacteremia rate, there were no readmissions to the index hospital within 6 weeks of discharge. Only two readmissions occurred within 3 years of discharge. This was surprising because inner city women might be expected to have higher rates of complication and readmission for acute pyelonephritis. Perhaps this is because of poorer general health care and lower compliance with antibiotic regimens as an outpatient. Though the patients might have been admitted to other hospitals, the socioeconomic class of many of these patients dictated use of this hospital almost exclusively. It is likely that repeat visits to the emergency room, which were not studied here, occurred. Letters were sent and phone calls were made that requested that the patients who were not seen in the clinic return for follow-up. This attempt yielded only four returns. Comparative Studies and Selection Criteria. The rate of bacteremia contrasts with evidence from many previous reports of the prevalence of bacteremic pyelonephritis. These reports from prospective case series, chart reviews, and drug studies ofpyelonephritis included men and older women. They demonstrated rates of bacteremia and urosepsis that ranged from 0% to 61% (Table 4).5-13,15-18 These studies suggested that young women with pyelonephritis tended not to have bacteremia. Factors that predisposed older women to pyelonephritis, which include acute and long-term instrumentation of the urinary tract and anatomic urinary tract abnormalities, were thought to affect the bacteremia rates and to account for the differences seen in the rates caused by age variation. 25 Both of these produced obstruction, contaminated the urinary tract, and resulted in the occurrence of more bacteremia. 5,8 Another study with selection criteria similar to those of this study was reported by Grover et a15; age was not a factor. Their study examined all patients admitted to a teaching hospital for presumed pyelonephritis. The bacteremia rate was lower than in the current study. Grover and his colleagues' study also used a combination of clinical criteria (> 5leukocytes per high-powered field, fever, and costovertebral angle tenderness), with positive results of urine or blood cultures, to stratify patients as more or less likely to have pyelonephritis. Using Grover's criteria, 16% of patients in his sample did not have pyelonephritis and 32% of the patients in our sample did not have pyelonephritis. The rate of negative results of urine cultures in our study was twice as high and

55

Bacteremia

thus accounted for our higher rate of diagnosis of "not pyelonephritis." Another analogous study by Pinson et aIls reported a retrospective cohort of patients who arrived at the emergency room of an academic medical center with fever and pyuria, which suggested pyelonephritis. In their sample, blood cultures were taken of 100% of 28 patients admitted to the hospital; eight (29%) were diagnosed with bacteremia. Blood cultures were taken of 4 of 83 patients in the sample who were not admitted to the hospital. The results of two of these cultures were positive. One of the two patients returned to the emergency room the next day with worsening symptoms and was admitted. The other was followed up by study personnel but did well without return to the hospital. Gleckman'sl6 and Dolan'sl7 reports specifically compared younger women versus older women in a subset analysis. Each report demonstrated disparate results; Gleckman found no bacteremia among younger women but did find a 48% rate in older women, whereas Dolan found a 27% rate in women both younger and older than 50. Dolan's findings were confirmed in this study by showing that bacteremia in young urban women with pyelonephritis might be more prevalent than was previously thought. Limitations. This study's size, its lack of completeness of culture collection, and its lack of generalizability were its chief limitations, and it therefore must be considered preliminary. The small size and incomplete culture collection prohibit building a predictive model for bacteremia. Further, the results cannot be generalized, especially the frequent occurrence of bacteremia, to the larger pool of women sent home from emergency rooms with symptomatic urinary tract infections. Undoubtedly, some of these women were sent home with bacteremia. Conclusions. Findings support that, in young urban women admitted with presumed pyelonephritis, physicians should forsake clinical stratification cues to determine the presence of bacteremia and should routinely order blood cultures. This reiterates Dolan et al'sl7 guideline for management of serious urinary tract infections, which is based on his chart review. Our review found no studies that determined whether longer, earlier treatment of bacteremic pyelonephritis in young women impacted morbidity or mortality. One study was found that showed 1 of 4 women not admitted with bacteremic pyelonephritis returned to the emergency room. IS If an impact on morbidity and mortality can be made by treatment, then predictive models of bacteremic pyelonephritis should be developed. A predictive model already has been developed for bacteremia in the general population of hospitalized patients26 ; it has not been validated in women who were admitted with urinary tract infections.

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C. Virulence factors and pap genotype in Escherichia Coli isolates from women with acute pyelonephritis, with or without bacteremia. Clin Infect Dis. 1993; 17:448-56. 22. Dowling KJ, Roberts JA, Kaack BM. P-Fimbriated Escherichia coli urinary tract infection: A clinical correlation. South Med J. 1987;80:1533-6. 23. Workowski KA, Suchland RJ, Pettinger MB, Stamm WE. Association of genital infection with specific Chlamydia trachomatis serovars and race. J Infect Dis. 1992;166:1445-9.

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24. Rubin RH, Fang LST, Jones SR, et at. Single-dose amoxicillin therapy for urinary tract infection. JAMA. 1980; 244:561-4. 25. Platt R. Diagnosis and empiric therapy of urinary tract infection in the seriously ill patient. Review ofInfectious Disease. 1983; 5(suppl 1):S65-73. 26. Bates DW, Cook EF, Goldman L, Lee TH. Predicting bacteremia in hospitalized patients: A prospectively validated model. Ann Intern Med. 1990; 113:495-500.

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