Discrediting microscopic pyuria and leucocyte esterase as diagnostic surrogates for infection in patients with lower urinary tract symptoms: results from a clinical and laboratory evaluation

Kupelian, Anthony; Horsley, Harry; Khasriya, Rajvinder; Amussah, Rasheedah T.; Badiani, Raj; Courtney, Angela M.; Chandhyoke, Nihil S.; Riaz, Usama; Savlani, Karishma; Moledina, Malik; Montes, S. Bezares; O'Connor, Dominic; Visavadia, Rakhee; Kelsey, M.C.; Rohn, Jennifer L.; Malone‐Lee, James

doi:10.1111/j.1464-410x.2012.11694.x

Cited by 50 publications

(61 citation statements)

References 27 publications

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“…When nitrites were combined with WBCs (nitrites and WBCs both positive) the DOR was 7.21, the highest of any of the examined urinary parameter. When the presence of WBCs alone was considered in our study the PPV and NPV were 44.3% and 87%, respectively, similar to the values reported by Kupelian et al in a study of more than 1,200 patients with lower urinary tract symptoms [18]. …”

Section: Discussionsupporting

confidence: 88%

Evaluating the Role of Urinalysis for Suspected Cystitis in Women Undergoing Pelvic Radiotherapy

Ol³

et al. 2016

International Journal of Gynecological Cancer

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Purpose To analyze the effectiveness of urinalysis parameters in predicting positive urine culture and to characterize urinary tract infections (UTIs) in gynecologic cancer patients receiving pelvic radiotherapy. Materials and Methods The records of 134 women receiving pelvic radiotherapy were retrospectively analyzed with a total of 241 urine specimens. Dipstick, urine microscopy, and urine culture data were recorded. Sensitivities, specificities, positive and negative predictive values (PPV and NPV), and diagnostic odds ratios (DOR) of dipstick and microscopy components for predicting positive urine culture were calculated. Organisms isolated from positive cultures and their antibiotic resistance data were recorded. Results A total of 84 (34.9%) urine cultures were positive for growth. The presence of either urine nitrites, leukocyte esterase (LE), or both had the highest sensitivity (91.7%) of all tested parameters for predicting a positive urine culture. The presence of both urine white blood cells (WBC) and urine nitrites had the highest specificity (95.5%), PPV (75.0%) and DOR (7.21 [2.92 – 17.83]) whereas the absence of urine WBCs had the highest NPV (87.0%). Escherichia coli was the most common grown in culture, isolated from 19 (22.6%) of specimens. When antibiotic sensitivity analysis was performed, 23.8% of pathogens were resistant to trimethoprim/sulfamethoxazole, 16.7% were resistant to ciprofloxacin, and 11.1% were resistant to nitrofurantoin. Conclusions UA may be less accurate for predicting UTI in women undergoing pelvic RT compared to the general population, but is still useful. Escherichia coli was less common than expected and the rate of resistance to first-line antibiotics was relatively high, underscoring the importance of culture and sensitivity testing in order to confirm the efficacy of empiric antibiotic therapy.

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Section: Discussionsupporting

confidence: 88%

Evaluating the Role of Urinalysis for Suspected Cystitis in Women Undergoing Pelvic Radiotherapy

Ol³

et al. 2016

International Journal of Gynecological Cancer

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“…Pyuria ≥10 WBC µl -1 has long been advocated as a diagnostic threshold to discriminate between the presence or absence of lower urinary tract pathology. First described by Dukes in 1928 [48], this diagnostic threshold does not withstand contemporary scientific scrutiny [16], and there are no published data demonstrating that pyuria of 1 to 9 WBC µl -1 is non-pathological [49]. Indeed, 1-9 WBC µl -1 does predict underlying disease [49], so we thought it prudent to include this category.…”

Section: Resultsmentioning

confidence: 99%

“…Our research centre and others have found that the tests deployed to screen for UTI are largely inadequate, particularly in patients who do not present with classic acute infective symptoms [14–16]. Although LUTS can undoubtedly be caused by other factors (e.g.…”

Section: Introductionmentioning

confidence: 99%

Enterococcus faecalis Subverts and Invades the Host Urothelium in Patients with Chronic Urinary Tract Infection

et al. 2013

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Bacterial urinary tract infections (UTI) are a major growing concern worldwide. Uropathogenic Escherichia coli has been shown to invade the urothelium during acute UTI in mice and humans, forming intracellular reservoirs that can evade antibiotics and the immune response, allowing recurrence at a later date. Other bacterial species, such as Staphylococcus saprophyticus, Klebsiella pneumonia and Salmonella enterica have also been shown to be invasive in acute UTI. However, the role of intracellular infection in chronic UTI causing more subtle lower urinary tract symptoms (LUTS), a particular problem in the elderly population, is poorly understood. Moreover, the species of bacteria involved remains largely unknown. A previous study of a large cohort of non-acute LUTS patients found that Enterococcus faecalis was frequently found in urine specimens. E. faecalis accounts for a significant proportion of chronic bladder infections worldwide, although the invasive lifestyle of this uropathogen has yet to be reported. Here, we wanted to explore this question in more detail. We harvested urothelial cells shed in response to inflammation and, using advanced imaging techniques, inspected them for signs of bacterial pathology and invasion. We found strong evidence of intracellular E. faecalis harboured within urothelial cells shed from the bladder of LUTS patients. Furthermore, using a culture model system, these patient-isolated strains of E. faecalis were able to invade a transitional carcinoma cell line. In contrast, we found no evidence of cellular invasion by E. coli in the patient cells or the culture model system. Our data show that E. faecalis is highly competent to invade in this context; therefore, these results have implications for both the diagnosis and treatment of chronic LUTS.

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“…4) We did this because of the widespread use of pyuria ≥10 WBC μl −1 as the threshold for “significant” pyuria [12], although results that incriminate pyuria between 1 and 9 have been published [2]. …”

Section: Methodsmentioning

confidence: 99%

Lower urinary tract symptoms that predict microscopic pyuria

Khasriya¹,

Barcella

Swamy³

et al. 2017

Int Urogynecol J

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Introduction and hypothesisUrinary dipsticks and culture analyses of a mid-stream urine specimen (MSU) at 105 cfu ml−1 of a known urinary pathogen are considered the gold standard investigations for diagnosing urinary tract infection (UTI). However, the reliability of these tests has been much criticised and they may mislead. It is now widely accepted that pyuria (≥1 WBC μl−1) detected by microscopy of a fresh unspun, unstained specimen of urine is the best biological indicator of UTI available. We aimed to scrutinise the greater potential of symptoms analysis in detecting pyuria and UTI.MethodsLower urinary tract symptom (LUTS) descriptions were collected from patients with chronic lower urinary tract symptoms referred to a tertiary referral unit. The symptoms informed a 39-question inventory, grouped into storage, voiding, stress incontinence and pain symptoms. All questions sought a binary yes or no response. A bespoke software package was developed to collect the data. The study was powered to a sample of at least 1,990 patients, with sufficient power to analyse 39 symptoms in a linear model with an effect size of Cohen’s f2 = 0.02, type 1 error probability = 0.05; and power (1-β); 95% where β is the probability of type 2 error). The inventory was administered to 2,050 female patients between August 2004 and November 2011. The data were collated and the following properties assessed: internal consistency, test–retest reliability, inter-observer reliability, internal responsiveness, external responsiveness, construct validity analysis and a comparison with the International Consultation on Incontinence Modular Questionnaire for female lower urinary tract symptoms (ICIQ-FLUTS). The dependent variable used as a surrogate marker of UTI was microscopic pyuria. An MSU sample was sent for routine culture.ResultsThe symptoms proved reliable predictors of microscopic pyuria. In particular, voiding symptoms correlated well with microscopic pyuria (χ2 = 88, df = 1, p < 0.001). The symptom inventory has significant psychometric characteristics as below: test–retest reliability: Cronbach’s alpha was 0.981; inter-observer reliability, Cronbach’s alpha was 0.995, internal responsiveness F = 221, p < 0.001, external responsiveness F = 359, df = 5, p < 0.001. The correlation coefficients for the domains of the ICIQ-FLUTS were around R = 0.5, p < 0.001.ConclusionThis symptoms score performed well on the standard, psychometric validation. The score changed in response to treatment and in a direction appropriate to the changes in microscopic pyuria. It correlated with measures of quality of life. It would seem to make a good candidate for monitoring treatment progress in ordinary clinical practice.

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Discrediting microscopic pyuria and leucocyte esterase as diagnostic surrogates for infection in patients with lower urinary tract symptoms: results from a clinical and laboratory evaluation

Cited by 50 publications

References 27 publications

Evaluating the Role of Urinalysis for Suspected Cystitis in Women Undergoing Pelvic Radiotherapy

Evaluating the Role of Urinalysis for Suspected Cystitis in Women Undergoing Pelvic Radiotherapy

Enterococcus faecalis Subverts and Invades the Host Urothelium in Patients with Chronic Urinary Tract Infection

Lower urinary tract symptoms that predict microscopic pyuria

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