Correspondence
Management of Urinary Tract Infections
N Engl J Med 1994; 330:792March 17, 1994
- Article
To the Editor:
In their excellent review of the management of urinary tract infections in adults (Oct. 28 issue),1 Stamm and Hooton comment that pyuria is “usually” present in patients with cystitis. Our experience is that pyuria is always present in adults with symptomatic bacterial cystitis. Is it not incorrect to diagnose a bacterial urinary tract infection in the absence of concomitant pyuria (generally defined as more than 10 neutrophils per high-power field of centrifuged urinary sediment)?
1 ReferencesDonald F. Middendorf, M.D.
Lee A. Hebert, M.D.
Ohio State University, Columbus, OH 43210-12281
Stamm WE ,Hooton TM . Management of urinary tract infections in adults. N Engl J Med 1993;329:1328-1334
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To the Editor:
Stamm and Hooton list trimethoprim-sulfamethoxazole as an option for the treatment of asymptomatic bacteriuria during the first trimester of pregnancy, without comment or caution regarding possible adverse effects. Both components cross the placenta and reach high levels in fetal serum, causing a risk of kernicterus and hemolysis in a fetus with glucose-6-phosphate dehydrogenase deficiency. Folate antagonists have teratogenic potential1. The Physicians' Desk Reference lists this agent in “Pregnancy Category C,” with the advice that it be prescribed with caution during pregnancy when the potential benefit is judged to exceed the potential risk2. Many are reluctant to prescribe this agent during pregnancy.
2 ReferencesDavid M. Hutt, M.D.
2400 Duffield Rd., Shaker Heights, OH 44122To the Editor:
In their informative review, Stamm and Hooton point out that urinary tract infections caused by urinary catheters result in considerable morbidity and occasional mortality and that prevention is the best strategy for avoiding complications. Unfortunately, they did not recommend avoiding the use of urinary catheters whenever possible. Although this suggestion may seem obvious, in some clinical settings urinary catheters are inserted almost routinely, without assessment of the potential risks and benefits. Patients with acute renal failure are often catheterized despite the presence of oliguria or anuria. This increases the risk of infection, which is a major cause of death in these patients. Similarly, patients treated for nonoliguric renal failure or pulmonary edema are often catheterized, even if alert.
Bladder catheterization is not a benign procedure. It is an invasive one with substantial risks that increase with the duration of catheterization. The urinary catheter should not be used in patients who can void normally.
Aaron Spital, M.D.
University of Rochester School of Medicine, Rochester, NY 14607Author/Editor Response
The authors reply:
To the Editor: Drs. Middendorf and Hebert assert that pyuria is always found in patients with bacterial cystitis1. Although we agree that pyuria nearly always accompanies acute cystitis, occasional patients may not have associated pyuria, either because the infection is in an early phase or because of laboratory methodologic errors1. The most sensitive and specific method of identifying pyuria -- counting leukocytes in uncentrifuged urine in a counting chamber -- is the approach that we recommend. Even using this method, however, we occasionally see patients with classic symptoms and bacteriuria with a single uropathogen who have no pyuria.
Many physicians prefer to use amoxicillin, nitrofurantoin, or cephalosporins as alternatives that may be safer than trimethoprim-sulfamethoxazole to treat asymptomatic bacteriuria during the first trimester of pregnancy. As indicated in the footnote to our Table 2, trimethoprim-sulfamethoxazole has not been approved for use in pregnancy. However, clinical experience suggests that the use of the drug in pregnancy is not associated with frequent or serious adverse effects on the fetus2. Thus, we consider it a reasonable alternative when allergy, intolerance, or antimicrobial resistance to the drugs mentioned above is present.
Finally, we agree with Dr. Spital that perhaps the most important means of preventing catheter-associated urinary tract infections is to avoid catheterization whenever possible, and we have emphasized this elsewhere3.
3 ReferencesWalter E. Stamm, M.D.
Thomas M. Hooton, M.D.
University of Washington School of Medicine, Seattle, WA 981041
Stamm WE . Measurement of pyuria and its relation to bacteriuria. Am J Med 1983;75:53-58
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Brumfitt W ,Pursell R . Trimethoprim-sulfamethoxazole in the treatment of bacteriuria in women. J Infect Dis 1973;128:Suppl:657-665
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Stamm WE . Catheter-associated urinary tract infections: epidemiology, pathogenesis, and prevention. Am J Med 1991;91:65S-71S
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