- Email: [email protected]
Urinary infections
URINARY Does
INFECTIONS
Optimal
Treatment
HARRY J, CAMPBELL,
Influence
Recurrence?
M.D.
From the Department of Urology, Kaiser Foundation Hospital, Los Angeles, California
ABSTRACT-Ninety-six patients with ucute urinary infections in a military hospitul setting were divided into those receiving “optimal” and those receiving “suboptimal” treatment. Most patients were dependents of uctive-duty military personnel. Over a period of time averaging five and four tenths months, the recurrence rate of urinary infections wus determined for each group. The results show that optimul treatment did not yield a lower recurrence rate.
Since many patients with one urinary infection have repeated episodes throughout their lifetimes, an important question is whether adequate antimicrobial therapy of an acute episode reduces the likelihood of subsequent episodes. This report investigates this question with a retrospective, cohort method.‘.” The study population consisted of military personnel and their dependents at a small military base in the western United States. The potential patient population numbered about 10,000 people. There were 5,400 outpatient visits per month in the clinic; the hospital had an average daily census of 35 patients. Thirteen physicians served this military community. Consultations among the physicians were readily available. All of the physicians were recent graduates of American medical schools, and six were “board eligible” in their specialty. Urologic consultation was obtainable from either a civilian urologist in the civilian community or an army medical center in a large metropolis 100 miles away. Method A total sample of all patients with urinary infections within a four-month period in 1970 was obtained in the following manner. The names of all patients who had abnormal urinalyses and quantitative urine culture reports were obtained from the hospital and clinic laboratory. An abnormal report was considered to be one which
UROL(X:Y
/
APRIL 1973
/
VOLUME I, NIJhlRER 4
showed either albuminuria, microscopic or gross hematuria, bacteriuria, or pyuria. An abnormal urine culture report was considered to be one with a quantitative count greater than 50,000 colonies per milliliter. The patients’ clinic and hospital charts were then reviewed. All patients in whom the physician made the diagnosis of a urinary infection (cystitis, pyelonephritis, “UTI,” or any similar wording) were included in the study population. If the physician thought that the urinalysis or culture report was spurious or the result of “contamination,” the patient was rejected from the study. Interviews with patients were then conducted, any time from three to eight months after the patient’s acute illness. The interview consisted of questions pertaining to the patient’s symp toms, past history of urinary infections, and her (his) subsequent clinical course. On the basis of the chart review, the patient interview, and an occasional interview of the physician to clear up confusing problems, a profile of the medical care offered to each patient was derived, including the outcome of treatment. Criteria for optimal diagnosis and treatment of patients with urinary infections were derived by interviewing the group of 13 physicians who treated the patients. On the basis oftheir answers, a common set of criteria was constructed. At least 87 per cent of the physicians agreed with each point in the set of criteria; most of the criteria met with 100 per cent agreement. The
335
criteria for optimal treatment of urinary infections were as follows: antibiotics should be pre1. Appropriate scribed for at least seven days for all patients, including those with cystitis and pyelonephritis. 2. A follow-up visit to the physician should occur within fourteen days of the beginning of treatment in children and within twenty-one days of the beginning of treatment in adults (either cystitis or pyelonephritis). 3. A urologic consultation should be obtained for all patients who had repeated or recurrent episodes of urinary infections (three or more episodes for females, two or more for males). 4. A voiding cystourethrogram should be obtained in all children who experience repeated episodes of urinary infections (two episodes for boys and three episodes for girls). 5. A serum creatinine (or blood urea nitrogen) and an intravenous urogram should be obtained on all patients with pyelonephritis or with repeated episodes of cystitis. The study population was then divided into optimally treated and suboptimally treated
TABLE I. Comparison versus suboptimally
of optimully treated treated groups
groups. The recurrence rate of the urinary infections was then calculated for each group and compared. Results Over the four-month period, II9 patients were diagnosed as having urinary infections. This number of patients represents an incidence of 3.6 per cent per year, which compares with other reports on incidence of urinary infections in a community.‘,4 Successful chart reviews and interviews with patients were completed on 96 of these (81 per cent). Using the treatment criteria, 45 patients (47 per cent) were determined to have had optimal treatment, and 51 (53 per cent) had suboptimal treatment. Table I describes the characteristics of each of these groups. The “cohort evaluation period” in Table I is the period of time from when the diagnosis was made to when the patient interview was conducted. Table II lists the urinary infection recurrence rates during the cohort evaluation period for both the optimally treated and the suboptimally treated groups. The recurrence rate for the optimally treated group was 36 per cent, whereas it was 20 per cent for the suboptimally treated group during the same follow-up period.
Characteristic Range in age (years) Median age (years) Cohort evaluation period Range (months) Average (months) Married (per cent) Caucasian (per cent) Female (per cent) Patients with first urinary infection (per cent) Patients with cystitis (per cent) Patients with pyelonephritis (per cent)
2 to 63 25
0.5 to 55 25
4 to 8 5.4 75 98 100
3 to 7.5 5.4 78 90 96
23
41
87
92
13
8
TABLE II. Recurrence rates of urinary infections during cohort evaluation period
Group Optimally treated Suboptimally treated
336
-C=lNumber
Recurrences One or ~Ior?-_l Per Cent Nnnlber Per Cent Totals
29
64
16
36
45
41
80
10
20
51
Comment The purpose of treating acute urinary infections is to reduce short-term suffering, to reduce the extent of parenchymal scarring in cases of pyelonephritis, and to prevent the extention of bladder infection into the kidney in cases of cystitis. It may be that short-term treatment of acute urinary infections does not prevent long-term morbidity rates. Freeman et aZ.‘s5 United States Public Health Service cooperative study dealing with long-term urinary antiseptic therapy in patients with repeated urinary infections may provide us with an important tool for the reduction of end-stage results of chronic urinary infections. The methodology used in this paper has certain advantages. Since the military families studied here are younger than the people who frequently seek care at civilian county-supported or community hospitals, sentative of the
they are probably American people
more reprethan most
hospital-selected groups. Surveying medical care administered in the military medical care systern is more apt to represent the natural history of the illness being studied. Since there is no
UROLO(:Y
/ APRIL 1973 / VOLUME 1, NUMBER 4
financial obstacle to the patient’s seeking care, the medical records are more likely to include all illness occurrences. The main limitation of this study is the short “cohort evaluation period.” The average interval of five and four-tenths months may not be long enough to evaluate truly the treatment outcomes. On the other hand, this short interval does have the advantage of minimizing the chance of losing patients because of migration. Since the study is concerned primarily with whether or not the patient has had a recurrence of the illness, five months appear to be an adequate period of time in which to determine this. It is very difficult to uncover patients with asymptomatic bacteriuria. Since these patients were not actively screened, no attempt was made to include them in this study. A further bias of this study may be the result of failure of some of the patients to return for follow-up evaluations. Whereas 100 per cent of the optimally treated patients returned to see their physicians, only 78 per cent of the suboptimally treated patients returned. One might expect the optimally treated group to have a higher recurrence rate simply because their physicians had a better chance to make a diagnosis, whether or not they had symptoms. Further inspection of the suboptimally treated group shows that 53 per cent did not return at
IJROLCX:Y
/ APRIL 1973 / VOLUME
I,NUMBEH4
all for a follow-up of the original infection. Another 25 per cent returned too late to satisfy the criteria. Among the suboptimally treated patients who received some sort of follow-up, even though it may have been inadequate, the recurrence rate was two and one-half times as high (28 versus 11 per cent) as among those patients who received no follow-up at all. Regarding comparisons between the optimally and suboptimally treated groups, Table I demonstrates that the two groups are very similar in terms of age, sex, race, marital status, cohort evaluation period, and frequency of cystitis (versus pyelonephritis). 1510 North Edgemont Los Angeles, California
Street 90027
References 1. KUNIN, C. hl.: The natural history of recurrent bacteriuria in school girls, New England J. Med. 282: 1443 (1970). 2. Idem: Bacteriuria, proteinuria, and urinary tract infections in females followed seven years, Pediatrics 41: 968 (1968). 3. FOX, J. P.: Prospective studies defined: .A comment on a report on the use of hospital data in epidemiologic research, Am. J. Epidemiol. 91: 231 (1970). 4. MOND, N. C.: Study of childhood urinary tract infection in general practice, Brit. M. J. 1: 602 (1970). H. A., et cd.: Prevention of recurrent bac5. FREEMAN, teriuria with continuous chemotherapy, Ann. Int. Med. 69: 655 (1968).
337
INFECTIONS
Optimal
Treatment
HARRY J, CAMPBELL,
Influence
Recurrence?
M.D.
From the Department of Urology, Kaiser Foundation Hospital, Los Angeles, California
ABSTRACT-Ninety-six patients with ucute urinary infections in a military hospitul setting were divided into those receiving “optimal” and those receiving “suboptimal” treatment. Most patients were dependents of uctive-duty military personnel. Over a period of time averaging five and four tenths months, the recurrence rate of urinary infections wus determined for each group. The results show that optimul treatment did not yield a lower recurrence rate.
Since many patients with one urinary infection have repeated episodes throughout their lifetimes, an important question is whether adequate antimicrobial therapy of an acute episode reduces the likelihood of subsequent episodes. This report investigates this question with a retrospective, cohort method.‘.” The study population consisted of military personnel and their dependents at a small military base in the western United States. The potential patient population numbered about 10,000 people. There were 5,400 outpatient visits per month in the clinic; the hospital had an average daily census of 35 patients. Thirteen physicians served this military community. Consultations among the physicians were readily available. All of the physicians were recent graduates of American medical schools, and six were “board eligible” in their specialty. Urologic consultation was obtainable from either a civilian urologist in the civilian community or an army medical center in a large metropolis 100 miles away. Method A total sample of all patients with urinary infections within a four-month period in 1970 was obtained in the following manner. The names of all patients who had abnormal urinalyses and quantitative urine culture reports were obtained from the hospital and clinic laboratory. An abnormal report was considered to be one which
UROL(X:Y
/
APRIL 1973
/
VOLUME I, NIJhlRER 4
showed either albuminuria, microscopic or gross hematuria, bacteriuria, or pyuria. An abnormal urine culture report was considered to be one with a quantitative count greater than 50,000 colonies per milliliter. The patients’ clinic and hospital charts were then reviewed. All patients in whom the physician made the diagnosis of a urinary infection (cystitis, pyelonephritis, “UTI,” or any similar wording) were included in the study population. If the physician thought that the urinalysis or culture report was spurious or the result of “contamination,” the patient was rejected from the study. Interviews with patients were then conducted, any time from three to eight months after the patient’s acute illness. The interview consisted of questions pertaining to the patient’s symp toms, past history of urinary infections, and her (his) subsequent clinical course. On the basis of the chart review, the patient interview, and an occasional interview of the physician to clear up confusing problems, a profile of the medical care offered to each patient was derived, including the outcome of treatment. Criteria for optimal diagnosis and treatment of patients with urinary infections were derived by interviewing the group of 13 physicians who treated the patients. On the basis oftheir answers, a common set of criteria was constructed. At least 87 per cent of the physicians agreed with each point in the set of criteria; most of the criteria met with 100 per cent agreement. The
335
criteria for optimal treatment of urinary infections were as follows: antibiotics should be pre1. Appropriate scribed for at least seven days for all patients, including those with cystitis and pyelonephritis. 2. A follow-up visit to the physician should occur within fourteen days of the beginning of treatment in children and within twenty-one days of the beginning of treatment in adults (either cystitis or pyelonephritis). 3. A urologic consultation should be obtained for all patients who had repeated or recurrent episodes of urinary infections (three or more episodes for females, two or more for males). 4. A voiding cystourethrogram should be obtained in all children who experience repeated episodes of urinary infections (two episodes for boys and three episodes for girls). 5. A serum creatinine (or blood urea nitrogen) and an intravenous urogram should be obtained on all patients with pyelonephritis or with repeated episodes of cystitis. The study population was then divided into optimally treated and suboptimally treated
TABLE I. Comparison versus suboptimally
of optimully treated treated groups
groups. The recurrence rate of the urinary infections was then calculated for each group and compared. Results Over the four-month period, II9 patients were diagnosed as having urinary infections. This number of patients represents an incidence of 3.6 per cent per year, which compares with other reports on incidence of urinary infections in a community.‘,4 Successful chart reviews and interviews with patients were completed on 96 of these (81 per cent). Using the treatment criteria, 45 patients (47 per cent) were determined to have had optimal treatment, and 51 (53 per cent) had suboptimal treatment. Table I describes the characteristics of each of these groups. The “cohort evaluation period” in Table I is the period of time from when the diagnosis was made to when the patient interview was conducted. Table II lists the urinary infection recurrence rates during the cohort evaluation period for both the optimally treated and the suboptimally treated groups. The recurrence rate for the optimally treated group was 36 per cent, whereas it was 20 per cent for the suboptimally treated group during the same follow-up period.
Characteristic Range in age (years) Median age (years) Cohort evaluation period Range (months) Average (months) Married (per cent) Caucasian (per cent) Female (per cent) Patients with first urinary infection (per cent) Patients with cystitis (per cent) Patients with pyelonephritis (per cent)
2 to 63 25
0.5 to 55 25
4 to 8 5.4 75 98 100
3 to 7.5 5.4 78 90 96
23
41
87
92
13
8
TABLE II. Recurrence rates of urinary infections during cohort evaluation period
Group Optimally treated Suboptimally treated
336
-C=lNumber
Recurrences One or ~Ior?-_l Per Cent Nnnlber Per Cent Totals
29
64
16
36
45
41
80
10
20
51
Comment The purpose of treating acute urinary infections is to reduce short-term suffering, to reduce the extent of parenchymal scarring in cases of pyelonephritis, and to prevent the extention of bladder infection into the kidney in cases of cystitis. It may be that short-term treatment of acute urinary infections does not prevent long-term morbidity rates. Freeman et aZ.‘s5 United States Public Health Service cooperative study dealing with long-term urinary antiseptic therapy in patients with repeated urinary infections may provide us with an important tool for the reduction of end-stage results of chronic urinary infections. The methodology used in this paper has certain advantages. Since the military families studied here are younger than the people who frequently seek care at civilian county-supported or community hospitals, sentative of the
they are probably American people
more reprethan most
hospital-selected groups. Surveying medical care administered in the military medical care systern is more apt to represent the natural history of the illness being studied. Since there is no
UROLO(:Y
/ APRIL 1973 / VOLUME 1, NUMBER 4
financial obstacle to the patient’s seeking care, the medical records are more likely to include all illness occurrences. The main limitation of this study is the short “cohort evaluation period.” The average interval of five and four-tenths months may not be long enough to evaluate truly the treatment outcomes. On the other hand, this short interval does have the advantage of minimizing the chance of losing patients because of migration. Since the study is concerned primarily with whether or not the patient has had a recurrence of the illness, five months appear to be an adequate period of time in which to determine this. It is very difficult to uncover patients with asymptomatic bacteriuria. Since these patients were not actively screened, no attempt was made to include them in this study. A further bias of this study may be the result of failure of some of the patients to return for follow-up evaluations. Whereas 100 per cent of the optimally treated patients returned to see their physicians, only 78 per cent of the suboptimally treated patients returned. One might expect the optimally treated group to have a higher recurrence rate simply because their physicians had a better chance to make a diagnosis, whether or not they had symptoms. Further inspection of the suboptimally treated group shows that 53 per cent did not return at
IJROLCX:Y
/ APRIL 1973 / VOLUME
I,NUMBEH4
all for a follow-up of the original infection. Another 25 per cent returned too late to satisfy the criteria. Among the suboptimally treated patients who received some sort of follow-up, even though it may have been inadequate, the recurrence rate was two and one-half times as high (28 versus 11 per cent) as among those patients who received no follow-up at all. Regarding comparisons between the optimally and suboptimally treated groups, Table I demonstrates that the two groups are very similar in terms of age, sex, race, marital status, cohort evaluation period, and frequency of cystitis (versus pyelonephritis). 1510 North Edgemont Los Angeles, California
Street 90027
References 1. KUNIN, C. hl.: The natural history of recurrent bacteriuria in school girls, New England J. Med. 282: 1443 (1970). 2. Idem: Bacteriuria, proteinuria, and urinary tract infections in females followed seven years, Pediatrics 41: 968 (1968). 3. FOX, J. P.: Prospective studies defined: .A comment on a report on the use of hospital data in epidemiologic research, Am. J. Epidemiol. 91: 231 (1970). 4. MOND, N. C.: Study of childhood urinary tract infection in general practice, Brit. M. J. 1: 602 (1970). H. A., et cd.: Prevention of recurrent bac5. FREEMAN, teriuria with continuous chemotherapy, Ann. Int. Med. 69: 655 (1968).
337