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Differences in the Bacteriology of Intestinal Loop Urinary Diversions
Vol. 104, Dec. Printed in U.S.A.
THE JOURNAL OF UROLOGY
Copyright © 1970 by The Williams & Wilkins Co.
DIFFERENCES IN THE BACTERIOLOGY OF INTESTINAL LOOP URINARY DIVERSIONS ROBERT N. NEEDHAM, MYRON M. SMITH
AND
JOHN M. MATSEN*
From the Departments of Laboratory Medicine, Urology and Pediatrics, University of Minnesota Medical School, Minneapolis, Minnesota
Intestinal loop urinary diversion is an effective method of long-term corrective management for urinary tract stasis or obstruction.1 However, patients with bacteria in the urine prior to diversion often continue to demonstrate bacteriuria after surgical establishment of the intestinal conduit.2-4 Hinman postulates that bacteriuria will persist after ureteroileostomy if the exchange of urine in the ureters or in the conduit takes longer than the doubling time of bacteria, usually 20 to 30 minutes in the case of coliform bacteria. 5 We have been unable to find any reports on bacteria associated with bacteriuria subsequent to ileal loop diversions. Our study is a preliminary report on the bacteriology of 40 patients on whom sufficient followup data were available to allow analysis. METHODS
The clinical course of 26 patients who had undergone intestinal conduit operations was assessed prospectively for up to 6 months. Retrospective data were also evaluated on these patients extending back to the time of their urinary diversion operation. In addition, the hospital records of 14 patients who had received an intestinal loop urinary diversion and on whom sufficient urine culture data were available were analyzed retrospectively only. Since sufficient Accepted for publication December 23, 1969. * Requests for reprints: Box 198, University of Minnesota Hospitals, 412 Union St., S.E., Minneapolis, Minnesota 55455. 1 Fraley, E. E. and Paulson, D. F.: Medical progress. Urologic surgery. New Engl. J. Med., 281: 355, 1969.
2 Small, M. P., Boyarsky, S. and Glenn, J. F.: Clinical and experimental evaluation of ileal segment urinary diversion. Amer. J. Surg., 116: 782,
1968.
3 Retik, A. B., Perlmutter, A. D. and Gross, R. E.: Cutaneous ureteroileostomy in children. New Engl. J. Med., 277: 217, 1967. 4 Kafetsioulis, A. and Swinney, J.: Urinary diversion by ileal conduit. A long-term follow-up. Brit. J. Urol., 40: 1, 1968. 5 Hinman, F., Jr.: Factors in bacteriuria after urinary diversion. Urol. Int., 23: 164, 1968.
pre-diversion urine culture data were unavailable on many patients, over-all University of Minnesota urine culture data for a period of 8 years and data from the literature with regard to chronic urinary tract infections were assessed. Incidence of bacterial species from these 2 sources was similar and was believed most likely to be representative of the pre-diversion species isolation pattern of these patients. Cultures in the prospective portion of this study were obtained by catheterization of the carefully cleansed stoma. It is thought that cultures in the retrospective portion of the study were similarly obtained since this is the routine method for obtaining loop diversion cultures in this hospital. RESULTS
Patients ranged from 1 to 67 years old (median 19, mean 25). A total of 1,589 months of followup (average 40 months per patient) was assessed. The followup period ranged from 1 month to 158 months. Two parameters were used to classify positive cultures: one including only those cultures in which any organism was present in quantities of 100,000 colonies per ml. and greater and another representing all cultures which demonstrated organism presence (see table). Species incidence was approximately the same with both parameters. A total of 576 cultures was taken resulting in 413 positive cultures (71.7 per cent) and in 55.4 per cent of these there were multiple organisms recovered (652 organisms from the 413 positive cultures, an average of 1.6 organisms per culture). There was an average of 4.5 changes in the type of organisms cultured and an average of 6.4 changes in the antibiotic used in treatment per patient studied. No attempt was made to correlate antibiotic usage to organism changes. In 51.0 per cent of all cultures (71.2 per cent of positive cultures) organisms were present in quantities of 100,000 colonies per ml. or greater for a single species. More than 1 organism was 831
832
NEEDHAM, SMITH AND MATSEN
Univ. of Minn.* Data
I
Urinary Loop Diversion Study
Organism
% Found in Quant. of 100,000 or Greater Colonies /Ml. Escherichia coli Proteus species, nonmirabilis Proteus mirabilis Alpha-streptococci (enterococci) Klebsiella Pseudomonas aeruginosa Staphylococci (coag +) Staphylococci (coag - ) Providence Beta streptococci Diphtheroids Enterobacter Citrobacter Pseudomonas fluorescens Herellea Serratia Candida albicans Mirna Other Total
% Found in Any No.
35.2 2. 7
12.3 11.2
12.0 11. 2
9. 7 9. 7
14. 1 7.5
18.9 10.4
18. 7 6. 9 2.3 3.4 I. 7 0.9 1.8 3.0 0. 7 0. 9 0.2 0. 3 1.4 0.1 0.4
20.8 11.4 0.6 0.9 3.0 0.6 o. 3 5.4 2.1 1.5 0.3 1.8 0.6 0.9 4. 7
16.4 12. 7 0.6 1.0 I. 8 0.5 1.2 4.5 2.3 1. 7 1.0 0.9 0.8 0.5 1.6
100.0
100.0
100. 0
* All urine cultures done 1961-1968 inclusive. Other figures from University of Minnesota data: total cultures-43,535, total positivecultures-17,560, total cultures with organisms in numbers greater than 100,000 per ml.-13,915, total positive cultures with multiple organisms isolated-5,516.
present in 47.7 per cent of the cultures demonstrating an organism in quantities of 100,000 colonies per ml. or greater. In only 1.6 per cent of all cultures no single species was present in quantity greater than 100,000 organisms per ml. but the sum total of all organisms present exceeded 100,000 colonies per ml. With only the figures derived from tabulating organisms present in quantities of 100,000 colonies per ml. and greater, organism incidence demonstrates that Klebsiella was present most often (20.8 per cent). Proteus mirabilis (14.1 per cent), E. coli (12.3 per cent), Pseudomonas aeruginosa (11.4 per cent) and non-mirabilis Proteus (11.2 per cent) were the next most commonly observed organisms. Enterococcus species (7.5 per cent) and Enterobacter (5.4 per cent) were less frequently noted. DISCUSSION
There are 4 points that should be stressed. 1) These patients had a high incidence of urine cultures demonstrating a bacterial strain present in greater than 100,000 organisms per ml.
after urinary diversion (51.0 per cent). Some bacterial growth was present in 71.7 per cent of all cultures. Noteworthy but impossible to correlate accurately with bacterial culture results was the fact that many of these culture results were obtained while patients were on antibiotic therapy. 2) In comparison with results reported with acute and chronic urinary infections, 5- 9 which one can assume also would represent the prediversion picture of these patients, the results in this post-diversion study show E. coli is not the most common organism found and indeed is found only about a third as often as it is in non-diversion studies. In our study E. coli is found considerably less often than Klebsiella. Klebsiella organisms were found in about the same incidence as in other studies but Proteus and Pseudomonas species were found more often, largely filling the incidence void left by E. coli. Comparison with University of Minnesota urine culture data over an 8-year period demonstrates similar incidence differences (see table). 3) The number of cultures demonstrating multiple organisms is also greater than that found routinely in patients with acute and chronic infections. Patients with urinary tract infections at the University of Minnesota demonstrated multiple organisms in 31.4 per cent of positive cultures as contrasted to the 55.4 per cent found in study patients (P < .01). 4) It is pertinent to note that in the patients analyzed for this report, no patient's urine was always sterile. Also, none of these patients escaped antibiotic treatment for bacteriuria. Prospective, controlled studies of bacteriuria and its treatment in patients with intestinal diversions are needed to define the significance of 6 Turck, M., Browder, A. A., Lindemeyer, IL I., Brown, N. K., Anderson, K. N. and Petersdorf, R. G.: Failure of prolonged treatment of chronic urinary-tract infections with antibiotics. New Engl. J. Med., 267: 999, 1962. 7 Freeman, R. B., Bramer, L., Brancato, F., Cohen, S. I., Garfield, C. F., Griep, R. J., Hinman, E. J., Richardson, J. A., Thurm, R. II., Urner, C. and Smith, W. M.: Prevention of recurrent bacteriuria with continuous chemotherapy. Ann. Intern. Med., 69: 655, 1968. 8 Kunin, C. M., Zacha, E. and Paquin, A. J., Jr.: Urinary-tract infections in schoolchildren. I. Prevalence of bacteriuria and associated urologic findings. New Engl. J. Med., 266: 1287, 1962. 9 Kunin, C. M. and Halmagyi, N. E.: Urinarytract infections in schoolchildren. II. Characterization of invading organisms. New Engl. J. Med., 266: 1297, 1962.
BACTERIOLOGY OF INTESTINAL LOOP URINARY DIVERSIONS
this bacteriuria and to develop improved methods of managing these patients. SUMMARY
Forty patients having intestinal loop urinary diversion operations were evaluated for a total of 1,589 followup months. Organisms were present in 71.3 per cent of all urine cultures obtained and were present in greater than 100,000 per ml. amounts in 51.0 per cent. Multiple organisms were found in 55.4 per cent of all positive cultures. Klebsiella strains represent 20.8 per cent of organisms cultured in greater than 100,000 colonies per ml., whereas Proteus
833
mirabilis (14.1 per cent), E. coli (12.3 per cent) and a wide variety of other species were found less often. All patients had bacteriuria on at least 1 occasion postoperatively and none escaped treatment with antibiotics. It would appear that patients with intestinal loop urinary diversions manifest a different pattern of organism isolation from that of patients with bacteriuria having intact urinary tracts, with a seeming high rate of positive cultures and a high incidence of multiple organisms in these cultures. Further study is needed to define the significance of bacteriuria in these patients and to analyze its treatment and possible prophylaxis.
THE JOURNAL OF UROLOGY
Copyright © 1970 by The Williams & Wilkins Co.
DIFFERENCES IN THE BACTERIOLOGY OF INTESTINAL LOOP URINARY DIVERSIONS ROBERT N. NEEDHAM, MYRON M. SMITH
AND
JOHN M. MATSEN*
From the Departments of Laboratory Medicine, Urology and Pediatrics, University of Minnesota Medical School, Minneapolis, Minnesota
Intestinal loop urinary diversion is an effective method of long-term corrective management for urinary tract stasis or obstruction.1 However, patients with bacteria in the urine prior to diversion often continue to demonstrate bacteriuria after surgical establishment of the intestinal conduit.2-4 Hinman postulates that bacteriuria will persist after ureteroileostomy if the exchange of urine in the ureters or in the conduit takes longer than the doubling time of bacteria, usually 20 to 30 minutes in the case of coliform bacteria. 5 We have been unable to find any reports on bacteria associated with bacteriuria subsequent to ileal loop diversions. Our study is a preliminary report on the bacteriology of 40 patients on whom sufficient followup data were available to allow analysis. METHODS
The clinical course of 26 patients who had undergone intestinal conduit operations was assessed prospectively for up to 6 months. Retrospective data were also evaluated on these patients extending back to the time of their urinary diversion operation. In addition, the hospital records of 14 patients who had received an intestinal loop urinary diversion and on whom sufficient urine culture data were available were analyzed retrospectively only. Since sufficient Accepted for publication December 23, 1969. * Requests for reprints: Box 198, University of Minnesota Hospitals, 412 Union St., S.E., Minneapolis, Minnesota 55455. 1 Fraley, E. E. and Paulson, D. F.: Medical progress. Urologic surgery. New Engl. J. Med., 281: 355, 1969.
2 Small, M. P., Boyarsky, S. and Glenn, J. F.: Clinical and experimental evaluation of ileal segment urinary diversion. Amer. J. Surg., 116: 782,
1968.
3 Retik, A. B., Perlmutter, A. D. and Gross, R. E.: Cutaneous ureteroileostomy in children. New Engl. J. Med., 277: 217, 1967. 4 Kafetsioulis, A. and Swinney, J.: Urinary diversion by ileal conduit. A long-term follow-up. Brit. J. Urol., 40: 1, 1968. 5 Hinman, F., Jr.: Factors in bacteriuria after urinary diversion. Urol. Int., 23: 164, 1968.
pre-diversion urine culture data were unavailable on many patients, over-all University of Minnesota urine culture data for a period of 8 years and data from the literature with regard to chronic urinary tract infections were assessed. Incidence of bacterial species from these 2 sources was similar and was believed most likely to be representative of the pre-diversion species isolation pattern of these patients. Cultures in the prospective portion of this study were obtained by catheterization of the carefully cleansed stoma. It is thought that cultures in the retrospective portion of the study were similarly obtained since this is the routine method for obtaining loop diversion cultures in this hospital. RESULTS
Patients ranged from 1 to 67 years old (median 19, mean 25). A total of 1,589 months of followup (average 40 months per patient) was assessed. The followup period ranged from 1 month to 158 months. Two parameters were used to classify positive cultures: one including only those cultures in which any organism was present in quantities of 100,000 colonies per ml. and greater and another representing all cultures which demonstrated organism presence (see table). Species incidence was approximately the same with both parameters. A total of 576 cultures was taken resulting in 413 positive cultures (71.7 per cent) and in 55.4 per cent of these there were multiple organisms recovered (652 organisms from the 413 positive cultures, an average of 1.6 organisms per culture). There was an average of 4.5 changes in the type of organisms cultured and an average of 6.4 changes in the antibiotic used in treatment per patient studied. No attempt was made to correlate antibiotic usage to organism changes. In 51.0 per cent of all cultures (71.2 per cent of positive cultures) organisms were present in quantities of 100,000 colonies per ml. or greater for a single species. More than 1 organism was 831
832
NEEDHAM, SMITH AND MATSEN
Univ. of Minn.* Data
I
Urinary Loop Diversion Study
Organism
% Found in Quant. of 100,000 or Greater Colonies /Ml. Escherichia coli Proteus species, nonmirabilis Proteus mirabilis Alpha-streptococci (enterococci) Klebsiella Pseudomonas aeruginosa Staphylococci (coag +) Staphylococci (coag - ) Providence Beta streptococci Diphtheroids Enterobacter Citrobacter Pseudomonas fluorescens Herellea Serratia Candida albicans Mirna Other Total
% Found in Any No.
35.2 2. 7
12.3 11.2
12.0 11. 2
9. 7 9. 7
14. 1 7.5
18.9 10.4
18. 7 6. 9 2.3 3.4 I. 7 0.9 1.8 3.0 0. 7 0. 9 0.2 0. 3 1.4 0.1 0.4
20.8 11.4 0.6 0.9 3.0 0.6 o. 3 5.4 2.1 1.5 0.3 1.8 0.6 0.9 4. 7
16.4 12. 7 0.6 1.0 I. 8 0.5 1.2 4.5 2.3 1. 7 1.0 0.9 0.8 0.5 1.6
100.0
100.0
100. 0
* All urine cultures done 1961-1968 inclusive. Other figures from University of Minnesota data: total cultures-43,535, total positivecultures-17,560, total cultures with organisms in numbers greater than 100,000 per ml.-13,915, total positive cultures with multiple organisms isolated-5,516.
present in 47.7 per cent of the cultures demonstrating an organism in quantities of 100,000 colonies per ml. or greater. In only 1.6 per cent of all cultures no single species was present in quantity greater than 100,000 organisms per ml. but the sum total of all organisms present exceeded 100,000 colonies per ml. With only the figures derived from tabulating organisms present in quantities of 100,000 colonies per ml. and greater, organism incidence demonstrates that Klebsiella was present most often (20.8 per cent). Proteus mirabilis (14.1 per cent), E. coli (12.3 per cent), Pseudomonas aeruginosa (11.4 per cent) and non-mirabilis Proteus (11.2 per cent) were the next most commonly observed organisms. Enterococcus species (7.5 per cent) and Enterobacter (5.4 per cent) were less frequently noted. DISCUSSION
There are 4 points that should be stressed. 1) These patients had a high incidence of urine cultures demonstrating a bacterial strain present in greater than 100,000 organisms per ml.
after urinary diversion (51.0 per cent). Some bacterial growth was present in 71.7 per cent of all cultures. Noteworthy but impossible to correlate accurately with bacterial culture results was the fact that many of these culture results were obtained while patients were on antibiotic therapy. 2) In comparison with results reported with acute and chronic urinary infections, 5- 9 which one can assume also would represent the prediversion picture of these patients, the results in this post-diversion study show E. coli is not the most common organism found and indeed is found only about a third as often as it is in non-diversion studies. In our study E. coli is found considerably less often than Klebsiella. Klebsiella organisms were found in about the same incidence as in other studies but Proteus and Pseudomonas species were found more often, largely filling the incidence void left by E. coli. Comparison with University of Minnesota urine culture data over an 8-year period demonstrates similar incidence differences (see table). 3) The number of cultures demonstrating multiple organisms is also greater than that found routinely in patients with acute and chronic infections. Patients with urinary tract infections at the University of Minnesota demonstrated multiple organisms in 31.4 per cent of positive cultures as contrasted to the 55.4 per cent found in study patients (P < .01). 4) It is pertinent to note that in the patients analyzed for this report, no patient's urine was always sterile. Also, none of these patients escaped antibiotic treatment for bacteriuria. Prospective, controlled studies of bacteriuria and its treatment in patients with intestinal diversions are needed to define the significance of 6 Turck, M., Browder, A. A., Lindemeyer, IL I., Brown, N. K., Anderson, K. N. and Petersdorf, R. G.: Failure of prolonged treatment of chronic urinary-tract infections with antibiotics. New Engl. J. Med., 267: 999, 1962. 7 Freeman, R. B., Bramer, L., Brancato, F., Cohen, S. I., Garfield, C. F., Griep, R. J., Hinman, E. J., Richardson, J. A., Thurm, R. II., Urner, C. and Smith, W. M.: Prevention of recurrent bacteriuria with continuous chemotherapy. Ann. Intern. Med., 69: 655, 1968. 8 Kunin, C. M., Zacha, E. and Paquin, A. J., Jr.: Urinary-tract infections in schoolchildren. I. Prevalence of bacteriuria and associated urologic findings. New Engl. J. Med., 266: 1287, 1962. 9 Kunin, C. M. and Halmagyi, N. E.: Urinarytract infections in schoolchildren. II. Characterization of invading organisms. New Engl. J. Med., 266: 1297, 1962.
BACTERIOLOGY OF INTESTINAL LOOP URINARY DIVERSIONS
this bacteriuria and to develop improved methods of managing these patients. SUMMARY
Forty patients having intestinal loop urinary diversion operations were evaluated for a total of 1,589 followup months. Organisms were present in 71.3 per cent of all urine cultures obtained and were present in greater than 100,000 per ml. amounts in 51.0 per cent. Multiple organisms were found in 55.4 per cent of all positive cultures. Klebsiella strains represent 20.8 per cent of organisms cultured in greater than 100,000 colonies per ml., whereas Proteus
833
mirabilis (14.1 per cent), E. coli (12.3 per cent) and a wide variety of other species were found less often. All patients had bacteriuria on at least 1 occasion postoperatively and none escaped treatment with antibiotics. It would appear that patients with intestinal loop urinary diversions manifest a different pattern of organism isolation from that of patients with bacteriuria having intact urinary tracts, with a seeming high rate of positive cultures and a high incidence of multiple organisms in these cultures. Further study is needed to define the significance of bacteriuria in these patients and to analyze its treatment and possible prophylaxis.