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Original Investigation |

The Relationship Between Pyuria and Infection in Patients With Indwelling Urinary Catheters:  A Prospective Study of 761 Patients FREE

Paul A. Tambyah, MBBS; Dennis G. Maki, MD
[+] Author Affiliations

From the Section of Infectious Diseases, Department of Medicine, University of Wisconsin Medical School, Madison.


Arch Intern Med. 2000;160(5):673-677. doi:10.1001/archinte.160.5.673.
Text Size: A A A
Published online

Background  Pyuria is universally considered as essential for identifying urinary tract infections in noncatheterized patients. The utility of pyuria in the catheterized patient, to identify catheter-associated urinary tract infection (CAUTI), has not been adequately defined.

Methods  We prospectively studied 761 newly catheterized patients in a university hospital; 82 (10.8%) developed nosocomial CAUTI (>103 colony-forming units per milliliter). While catheterized, each patient was seen daily, a quantitative urine culture was obtained, and the urine white blood cell concentration was measured quantitatively using a hemocytometer.

Results  The mean urine leukocyte count in patients with CAUTI was significantly higher than in patients without infections (71 vs 4 per microliter; P=.006). Pyuria was most strongly associated with CAUTI caused by gram-negative bacilli (white blood cell count, 121 vs 4 per microliter; P=.03); infection with coagulase-negative staphylococci and enterococci (white blood cell count, 39 vs 4 per microliter; P=.25) or yeasts (white blood cell count, 25 vs 4 per microliter; P=.15) produced much less pyuria. Pyuria with a white blood cell count greater than 10 per microliter (>5 per high-power field in a conventional urinalysis) had a specificity of 90% for predicting CAUTI with greater than 105 colony-forming units per milliliter but a sensitivity of only 37%.

Conclusions  In patients with short-term indwelling urinary catheters, pyuria is less strongly correlated with CAUTI than in noncatheterized patients with urinary tract infection. The strongest association is with CAUTI caused by gram-negative bacilli; the association is far weaker for infections caused by gram-positive cocci or yeasts. Most patients with CAUTI are asymptomatic and do not have associated fever. Pyuria should not be used as the sole criterion to obtain a urine culture in a patient with a catheter.

Figures in this Article

CATHETER-ASSOCIATED urinary tract infection (CAUTI) is the most common nosocomial infection, accounting for up to 40% of all nosocomial infections and more than 1 million infections in US hospitals each year.13 Up to a half of patients requiring an indwelling urethral catheter for 5 days or longer will develop bacteriuria or candiduria.13 Silent catheter-associated bacteriuria comprises a huge reservoir of resistant organisms in the hospital, particularly on critical care units.413

Pyuria has been shown to have excellent predictive value for identifying urinary tract infections in noncatheterized patients.14,15 Although recently published guidelines16 recommend using pyuria as the criterion for obtaining a urine culture as part of the workup of fever in the hospitalized patient, the utility of pyuria for identifying bacteriuria or candiduria in patients with a short-term catheter has not been clearly defined.

We report the results of a prospective study of the relationship between pyuria and urinary tract infection in 761 hospitalized patients with short-term indwelling urinary catheters.

PATIENTS

Patients participating in 2 prospective, randomized, comparative trials of medicated catheters, one a nitrofurazone-impregnated silicone catheter17 and the other a silver-polyurethane hydrogel catheter,18 formed the population studied. Neither medicated catheter was associated with any irritative urinary tract symptoms or with sterile pyuria compared with the control catheters used in each trial.17,18 Participants in both trials were hospitalized patients scheduled to receive an indwelling urethral (Foley) catheter who were expected to be catheterized for more than 24 hours. Patients were excluded if they were younger than 18 years; pregnant; or had a known allergy to silicone, nitrofurazone, or silver. Both studies were approved by the Human Subjects Committee of the University of Wisconsin–Madison Center for Health Sciences, and written informed consent was obtained from all patients.

On enrollment into the study, baseline demographic and clinical data bearing on risk factors for CAUTI1921 were collected, including age, sex, structural urologic disease, underlying systemic diseases including diabetes mellitus and cancer, immunosuppressive therapy, hospital service, confinement in an intensive care unit, severity of illness using the Acute Physiology and Chronic Health Evaluation II score, recent surgery, and the purpose for catheterization.

On enrollment, and daily thereafter, approximately 3 mL of urine was aspirated from the sampling port of the catheter with a sterile syringe, first disinfecting the port with 10% povidone-iodine. Each specimen was immediately brought to the laboratory and cultured using a technique capable of detecting 1 colony-forming unit (CFUs) per milliliter,22 evenly spreading 1 mL of undiluted urine and serial dilutions on predried sheep blood agar plates. After aerobic incubation at 37°C for 24 to 48 hours, each colony type was enumerated and fully identified using standard techniques and criteria.23

Quantitative urine white blood cell counts were measured daily using a hemocytometer (Hausser Scientific Partnership, Horsham, Pa).24 Every day, in addition to the urine culture, the patient was questioned regarding any discomfort or symptoms associated with the catheter (pain, sense of urgency, or dysuria). Patients' medical records were reviewed concurrently for fever or other clinical and laboratory data suggesting active infection. Peripheral white blood cell counts were recorded as they were ordered by patients' physicians.

DEFINITION OF CAUTI

The new appearance of bacteriuria or funguria of greater than 103 CFUs per milliliter was considered to represent nosocomial CAUTI. We have previously shown that isolation of greater than 103 CFUs per milliliter is highly predictive of CAUTI22; with greater than 103 CFUs per milliliter bacteriuria or candiduria, if intercurrent antimicrobial therapy is not given to the patient, the level of bacteriuria or candiduria uniformly rises to greater than 105 CFUs per milliliter within 24 to 48 hours, as confirmed in this study.

STATISTICAL ANALYSIS

The Student unpaired t test was used to determine the significance of differences with continuous variables; and the Fisher exact test, for dichotomous data. Two-tailed tests of significance were used exclusively.

A total of 1035 evaluable newly catheterized patients participated in this study. To accurately assess the significance of pyuria in patients with an indwelling urinary catheter, we excluded patients who underwent a kidney or a kidney-pancreas transplantation, who we have found show a burst of sterile leukocyturia immediately after transplantation (P.A.T. and D.G.M., unpublished data, 1998), and analyzed 761 catheterized patients, of whom 82 (10.8%) developed 95 nosocomial CAUTIs.

The incidence of CAUTI was much higher in women than men (50 [21.2%] of 236 vs 32 [7.2%] of 443; relative risk, 2.9; 95% confidence interval, 2.1-4.2; P<.001). Of the 95 CAUTIs, 89 (94%) were unimicrobial and 6 (6%) were polymicrobial, most commonly with enterococci and gram-negative bacilli; 14 infections (14%) were caused by Escherichia coli, 27 (27%) by Klebsiella, Enterobacter, Citrobacter, Pseudomonas aeruginosa, or other resistant nosocomial gram-negative bacilli, 27 (27%) by enterococci or staphylococci, and 31 (31%) by Candida species. Only 50 (53%) of the 95 CAUTIs were detected by the primary team taking care of the patients; more than half of the CAUTIs were not treated.

As can be seen in Table 1, except for sex, duration of catheterization, and type of service, patients with and without CAUTI were quite similar, including severity of illness, as measured by the Acute Physiology and Chronic Health Evaluation II score. Moreover, most patients were asymptomatic, including those with CAUTI,25 and mean peripheral white blood cell counts were similar in patients with and without CAUTI.

Table Graphic Jump LocationTable 1. Epidemiological Characteristics of 82 Patients With Nosocomial CAUTI Among 761 Catheterized Patients Prospectively Studied*

The mean urine white blood cell count in patients with CAUTI during active infection was significantly higher than in uninfected patients (71 vs 4 per microliter, P=.006) (Table 2). Pyuria was most strongly associated with infection caused by gram-negative bacilli (mean urine white cell count, 121 vs 4 per microliter, P=.03). In contrast, CAUTI caused by coagulase-negative staphylococci and enterococci (39 vs 4 per microliter, P=.25) or yeasts (25 vs 4 per microliter, P=.15) produced far less pyuria.

Table Graphic Jump LocationTable 2. Urine White Blood Cell Counts in Hospitalized Patients With Catheters*

Although the maximum level of pyuria was considerably higher than the mean during the period of catheterization, in patients with and without CAUTI, the discrimination between uninfected and infected patients using maximum urine white blood cell counts was no better than using mean values (Table 2). Urine white blood cell counts on the day of onset of bacteriuria or candiduria greater than 103 CFUs per milliliter were only modestly elevated and were not useful for the prediction of CAUTI (Table 2). The absolute level of bacteriuria or candiduria did not correlate with the level of pyuria except at very high microbial concentrations, greater than 108 CFUs per milliliter (Figure 1).

Place holder to copy figure label and caption

Relationship between levels of bacteriuria or candiduria and quantitative pyuria in 761 catheterized patients. Data are depicted on a log-log scale, for clarity; colony counts between 1 and 103 colony-forming units per milliliter are not shown. Each point represents 1 catheter-day. It can be seen (curvilinear regression line) that the relationship between urine microbial counts and pyuria in the catheterized patient is weak until very high levels of bacteriuria or candiduria are reached.

Graphic Jump Location

The sensitivity of pyuria greater than 10 white blood cells per microliter in a fresh urine specimen (which corresponds roughly to >5 per high-power field in a microscopic examination of the urine sediment24) for the diagnosis of CAUTI with greater than 103 CFUs per milliliter was only 37%; specificity, 90%; and positive predictive value, 36%; for the diagnosis of CAUTI with greater than 105 CFUs per milliliter, sensitivity was only 47%; specificity, 90%; and positive predictive value, 32% (Table 3).

Table Graphic Jump LocationTable 3. Utility of Pyuria for the Diagnosis of CAUTI*

The association between pyuria in a spontaneously voided urine specimen and urinary tract infection in noncatheterized patients is based on the studies of Brumfitt26 and Little.27 A urinary leukocyte excretion rate, as measured in a counting chamber, of greater than 400 000 per hour was found by Hutt et al28 and Gadeholt29 to be the upper limit of normal and correlated with a quantitative urine white blood cell count of approximately 10 per microliter in a single examination of uncentrifuged urine. In a review24 of the 5 published studies using counting chamber urine leukocyte determinations, 281 of 291 symptomatic patients with bacteriuria had a white blood cell count greater than 10 per microliter (sensitivity, 97%; specificity, 98%; and positive predictive value, 98%). Since then, pyuria has become universally regarded as an essential criterion for the diagnosis of urinary tract infection.1,3032 Pyuria has also been recommended as the indication to obtain a urine culture in patients with fever in the intensive care unit in a recent consensus guideline.16

In patients with indwelling urinary catheters, the association of pyuria with bacteriuria has been studied primarily in those with spinal cord injury undergoing intermittent catheterization or in those with long-term indwelling catheters. In a study of 32 patients with chronic infections, Peterson and Roth33 found that 50 white blood cells per high-power field in microscopic examination of urinary sediment separated their cohort into a high pyuria group, 6 of 10 who had fever and symptomatic urinary tract infection, and a low pyuria group, of which only 3 of 22 had fever or other symptoms. However, Gribble et al,34 studying a population of intermittently catheterized patients with spinal cord injury, reported that measurement of the quantitative level of pyuria did not separate bacteriuric from abacteriuric patients. Musher et al35 reported that pyuria with a white blood cell count greater than 10 per microliter had a sensitivity of 86% and a specificity of 73% for the diagnosis of CAUTI with greater than 103 CFUs per milliliter; for CAUTI with greater than105 CFUs per milliliter, the sensitivity was 91% and the specificity was 72%. However, most of their patients were undergoing long-term catheterization, women were not studied, and patients with candiduria were excluded. The utility of pyuria for the identification of CAUTI in hospitalized patients with short-term indwelling urinary catheters has not been adequately defined.

In this large prospective study of hospitalized patients with catheters, with a wide but typical range of underlying conditions, nearly all of the patients with documented CAUTI were asymptomatic for fever or irritative symptoms referable to the urinary tract.25 Yet, patients with CAUTI did show on average a substantial and significant elevation of the mean urine white blood cell count during the period of active infection (Table 1). However, when infections were analyzed by the organism causing infection, pyuria was most strongly associated with CAUTI caused by gram-negative bacilli (121 vs 4 per microliter, P=.03; Table 2); infection caused by coagulase-negative staphylococci and enterococci or yeasts was much less strongly associated with pyuria. On the first day of bacteriuria or candiduria, the mean level of pyuria in patients infected with staphylococci and enterococci or yeasts differed little from that of uninfected patients (8 and 9 per microliter, respectively, vs 5 per microliter). Others have recently reported the frequent absence of pyuria in noncatheterized and catheterized patients with urinary tract infection caused by coagulase-negative staphylococci36 or yeasts.37

The reasons underlying these observations are not entirely clear. While CAUTI caused by staphylococci, enterococci, or yeasts occasionally leads to bloodstream infection, especially if urinary tract obstruction occurs,38 the degree of urinary tract inflammation elicited by these organisms is clearly not as great as occurs with the gram-negative bacilli. Coagulase-negative staphylococci have been shown in animal models of infection to incite far less cytokine release than gram-negative bacilli.39 Symptomatic community-acquired urinary tract infections in noncatheterized patients have been associated with more virulent, "pyelonephritogenic" strains of E coli,4042 but most nosocomial gram-negative bacillar CAUTIs are caused by P aeruginosa, Enterobacter species, and other enteric gram-negative bacilli2,3,43 for which urovirulence characteristics have yet to be characterized.

The clinical relevance of our findings seems clear. Pyuria cannot and should not be used as the sole criterion for obtaining a urine culture in a catheterized patient. This is especially true in the case of infections caused by yeasts and gram-positive cocci. It is clear that most patients with CAUTI are asymptomatic and do not have fever caused by CAUTI.25 If a catheterized patient develops fever or signs of sepsis that cannot be linked to another source, such as nosocomial pneumonia, surgical site infection, or vascular catheter-related bloodstream infection, a urine culture should be obtained even if the patient does not have demonstrable pyuria.

In this study of catheter-associated pyuria, we used a counting chamber to determine quantitative urine white blood cell counts. Most clinical laboratories measure pyuria semiquantitatively, reporting the number of white blood cells per microscopic high-power field in a centrifuged urine specimen. Although more than 5 white blood cells per high-power field correlates roughly with a urine white blood cell count greater than 10 per microliter,24 assessment of pyuria by semiquantitative microscopic examination of the urinary sediment has been shown to have a high degree of interobserver variability44 and may not be reliable as a diagnostic test. Semiquantitative pyuria by microscopy may have even poorer predictive value for diagnosing CAUTI.

Accepted for publication May 6, 1999.

This study was supported by research grants from Bard International, Covington, Ga; and Rochester Medial Inc, Rochester, Minn. Dr Tambyah is the recipient of a Singapore National Medical Research Council Fellowship.

Presented in part at the 38th Interscience Conference on Antimicrobial Agents and Chemotherapy, San Diego, Calif, September 27, 1998.

We thank Kathleen Halvorson, MS, Leah Narans, BS, and Shelly Fischer, BS, for their excellent laboratory support; and the research nurses, Valerie Knasinski, BSN, Jo Thomson, LPN, Pam Owen, LPN, Sharon Little, LPN, Josh Knox, BS, Ann Kelly, LPN, Julie Jurss, LPN, Anne Jones, LPN, Pat Gwinn, LPN, Carol Boone, LPN, Rose Bauer, LPN, and Lani Arrieta, BSN, for their collection of data during this study.

Reprints: Dennis G. Maki, MD, University of Wisconsin Hospital and Clinics, 600 Highland Ave, Room H4/574, Madison, WI 53792 (e-mail: dgmaki@facstaff.wisc.edu).

Kunin  CM Care of the urinary catheter. Urinary Tract Infections: Detection, Prevention and Management. 5th ed. Philadelphia, Pa Lippincott Williams & Wilkins1997;227- 279
Stamm  WE Catheter-associated urinary tract infections: epidemiology, pathogenesis and prevention. Am J Med. 1991;91(suppl 3B)65S- 71S
Link to Article
Warren  JW Catheter-associated urinary tract infections. Infect Dis Clin North Am. 1997;11609- 622
Link to Article
Siebert  JDThomson  RBTan  JSGerson  LW Emergence of antimicrobial resistance in gram-negative bacilli causing bacteremia during therapy. Am J Clin Pathol. 1993;10047- 51
Jarlier  VFosse  TPhilippon  A Antibiotic susceptibility in aerobic gram-negative bacilli isolated in intensive care units in 39 French teaching hospitals. Intensive Care Med. 1996;221057- 1065
Link to Article
Bjork  DTPelletier  LLTight  RR Urinary tract infections with antibiotic resistant organisms in catheterized nursing home patients. Infect Control. 1984;5173- 176
Gaynes  RPWeinstein  RAChamberlin  WKabins  S Antibiotic-resistant flora in nursing home patients admitted to the hospital. Arch Intern Med. 1985;1451804- 1807
Link to Article
Kirby  WMMCorpron  DOTanner  DC Urinary tract infections caused by antibiotic-resistant coliform bacilli. JAMA. 1956;1621- 4
Link to Article
Schaberg  DRHaley  RWHighsmith  AKAnderson  RLMcGowan  JE Nosocomial bacteriuria: a prospective study of case clustering and antimicrobial resistance. Ann Intern Med. 1980;93420- 424
Link to Article
Lam  SSinger  CTucci  VMorthland  VHPfaller  MAIsenberg  HD The challenge of vancomycin-resistant enterococci: a clinical and epidemiologic study. Am J Infect Control. 1995;23170- 180
Link to Article
Shlaes  DMLehman  MHCurrie-McCumber  CAKim  CHFloyd  R Prevalence of colonization with antibiotic resistant gram-negative bacilli in a nursing home care unit: the importance of cross-colonization as documented by plasmid analysis. Infect Control. 1986;7538- 545
Rice  LWilley  SHPapanicolau  GA  et al.  Outbreak of ceftazidime resistance caused by extended-spectrum β-lactamases at a Massachusetts chronic-care facility. Antimicrob Agents Chemother. 1990;342193- 2199
Link to Article
Naber  KGWitte  WBauernfeind  A  et al.  Clinical significance and spread of fluoroquinolone resistant uropathogens in hospitalised urological patients. Infection. 1994;22(suppl 2)S122- S127
Link to Article
Mabeck  CE Studies in urinary tract infections, IV: urinary leukocyte excretion in bacteriuria. Acta Med Scand. 1969;186193- 198
Link to Article
Stamm  WERunning  KMcKevitt  M  et al.  Treatment of the acute urethral syndrome. N Engl J Med. 1981;304956- 958
Link to Article
O'Grady  NPBarie  PSBartlett  J  et al.  Practice parameters for evaluating new fever in critically ill adult patients. Crit Care Med. 1998;26392- 408
Link to Article
Maki  DGKnasinski  VTambyah  PA A prospective investigator-blinded trial of a novel nitrofurazone-impregnated indwelling urinary catheter [abstract]. Infect Control Hosp Epidemiol. 1997;18(suppl)50Abstract M49.
Maki  DGKnasinski  VHalvorson  KTambyah  PA A novel silver-hydrogel–impregnated indwelling catheter reduces CAUTIs: a prospective double-blind trial.  Paper presented at: Society for Healthcare Epidemiology in America Annual Meeting April 5, 1998 Orlando, Fla.
Garibaldi  RABurke  JPDickman  MLSmith  CB Factors predisposing to bacteriuria during indwelling urethral catheterization. N Engl J Med. 1974;291215- 219
Link to Article
Platt  RPolk  BFMurdock  BRosner  B Risk factors for nosocomial urinary tract infection. Am J Epidemiol. 1986;124977- 985
Burke  JPRiley  DK Nosocomial urinary tract infections. Mayhall  CGed.Hospital Epidemiology and Infection Control. Philadelphia, Pa Lippincott Williams & Wilkins1996;139- 153
Stark  RPMaki  DG Bacteriuria in the catheterized patient: what quantitative level of bacteriuria is relevant? N Engl J Med. 1984;311560- 564
Link to Article
Balows  LEedHausler  WedShadomy  Hed Manual of Clinical Microbiology. 5th ed. Washington, DC American Society for Microbiology1991;
Stamm  WE Measurement of pyuria and its relation to bacteriuria. Am J Med. 1983;75(suppl 1B)53- 58
Link to Article
Tambyah  PAMaki  DG Catheter-associated urinary tract infection is rarely symptomatic: a prospective study of 1497 catheterized patients. Arch Intern Med. 2000;160678- 682
Brumfitt  W Urinary cell counts and their value. J Clin Pathol. 1965;18550- 555
Little  PJ Diagnostic criteria of pyelonephritis. J Clin Pathol. 1965;18556- 558
Hutt  MSRChalmers  JAMacDonald  JSdeWardener  HE Pyelonephritis: observations on the relation between various diagnostic procedures. Lancet. 1961;1351- 357
Link to Article
Gadeholt  H Quantitative estimation of cells in urine. Acta Med Scand. 1968;183369- 374
Link to Article
Warren  JWMobley  HLT Urinary Tract Infections: Molecular Pathogenesis and Clinical Management.  Washington, DC American Society for Microbiology Press1996;
Kaye  D Urinary Tract Infection and Its Management.  St Louis, Mo Mosby–Year Book Inc1972;
Stamm  WE Criteria for the diagnosis of urinary tract infection and for the assessment of therapeutic effectiveness. Infection. 1992;20(suppl 3)S151- S154
Link to Article
Peterson  JRRoth  EJ Fever, bacteriuria and pyuria in spinal cord injured patients with indwelling urethral catheters. Arch Phys Med Rehabil. 1989;70839- 841
Gribble  MJPuterman  MLMcCallum  NM Pyuria: its relationship to bacteriuria in spinal cord injured patients on intermittent catheterization. Arch Phys Med Rehabil. 1989;70376- 379
Musher  DMThorsteinsson  SBAirola  VM Quantitative urinalysis: diagnosing urinary tract infection in men. JAMA. 1976;2362069- 2072
Link to Article
Rimland  DAlexander  W Absence of factors associated with significant urinary tract infections caused by coagulase-negative staphylococci. Diagn Microbiol Infect Dis. 1989;12123- 127
Link to Article
Huang  CTLeu  HSKo  WC Pyuria and funguria. Lancet. 1995;346582- 583
Link to Article
Quintiliani  RCunha  BKlimek  JMaderazo  EG Bacteremia after manipulation of the urinary tract: the importance of pre-existing urinary tract disease and compromised host defences. Postgrad Med J. 1978;54668- 671
Link to Article
Wakabayashi  GGelfland  JAJung  WKConnolly  RJBurke  JFDinarello  CA Staphylococcus epidermidis induces complement activation, tumor necrosis factor and interleukin-1, a shock-like state and tissue injury in rabbits without endotoxemia: comparison to Escherichia coliJ Clin Invest. 1991;871925- 1935
Link to Article
Johnson  JR Virulence factors in Escherichia coli urinary tract infection. Clin Microbiol Rev. 1991;480- 128
Ulleryd  PLincoln  KScheutz  FSandberg  T Virulence characteristics of E coli in relation to host response in men with symptomatic urinary tract infection. Clin Infect Dis. 1994;18579- 584
Link to Article
Stamm  WEHooton  TMJohnson  JR  et al.  Urinary tract infections: from pathogenesis to treatment. J Infect Dis. 1989;159400- 406
Link to Article
Bronsema  DAAdams  JRPallares  RWenzel  RP Secular trends in rates and etiology of nosocomial urinary tract infections at a university hospital. J Urol. 1993;150414- 416
Little  PJ Urinary white cell excretion. Lancet. 1962;11149- 1151
Link to Article

Figures

Place holder to copy figure label and caption

Relationship between levels of bacteriuria or candiduria and quantitative pyuria in 761 catheterized patients. Data are depicted on a log-log scale, for clarity; colony counts between 1 and 103 colony-forming units per milliliter are not shown. Each point represents 1 catheter-day. It can be seen (curvilinear regression line) that the relationship between urine microbial counts and pyuria in the catheterized patient is weak until very high levels of bacteriuria or candiduria are reached.

Graphic Jump Location

Tables

Table Graphic Jump LocationTable 1. Epidemiological Characteristics of 82 Patients With Nosocomial CAUTI Among 761 Catheterized Patients Prospectively Studied*
Table Graphic Jump LocationTable 2. Urine White Blood Cell Counts in Hospitalized Patients With Catheters*
Table Graphic Jump LocationTable 3. Utility of Pyuria for the Diagnosis of CAUTI*

References

Kunin  CM Care of the urinary catheter. Urinary Tract Infections: Detection, Prevention and Management. 5th ed. Philadelphia, Pa Lippincott Williams & Wilkins1997;227- 279
Stamm  WE Catheter-associated urinary tract infections: epidemiology, pathogenesis and prevention. Am J Med. 1991;91(suppl 3B)65S- 71S
Link to Article
Warren  JW Catheter-associated urinary tract infections. Infect Dis Clin North Am. 1997;11609- 622
Link to Article
Siebert  JDThomson  RBTan  JSGerson  LW Emergence of antimicrobial resistance in gram-negative bacilli causing bacteremia during therapy. Am J Clin Pathol. 1993;10047- 51
Jarlier  VFosse  TPhilippon  A Antibiotic susceptibility in aerobic gram-negative bacilli isolated in intensive care units in 39 French teaching hospitals. Intensive Care Med. 1996;221057- 1065
Link to Article
Bjork  DTPelletier  LLTight  RR Urinary tract infections with antibiotic resistant organisms in catheterized nursing home patients. Infect Control. 1984;5173- 176
Gaynes  RPWeinstein  RAChamberlin  WKabins  S Antibiotic-resistant flora in nursing home patients admitted to the hospital. Arch Intern Med. 1985;1451804- 1807
Link to Article
Kirby  WMMCorpron  DOTanner  DC Urinary tract infections caused by antibiotic-resistant coliform bacilli. JAMA. 1956;1621- 4
Link to Article
Schaberg  DRHaley  RWHighsmith  AKAnderson  RLMcGowan  JE Nosocomial bacteriuria: a prospective study of case clustering and antimicrobial resistance. Ann Intern Med. 1980;93420- 424
Link to Article
Lam  SSinger  CTucci  VMorthland  VHPfaller  MAIsenberg  HD The challenge of vancomycin-resistant enterococci: a clinical and epidemiologic study. Am J Infect Control. 1995;23170- 180
Link to Article
Shlaes  DMLehman  MHCurrie-McCumber  CAKim  CHFloyd  R Prevalence of colonization with antibiotic resistant gram-negative bacilli in a nursing home care unit: the importance of cross-colonization as documented by plasmid analysis. Infect Control. 1986;7538- 545
Rice  LWilley  SHPapanicolau  GA  et al.  Outbreak of ceftazidime resistance caused by extended-spectrum β-lactamases at a Massachusetts chronic-care facility. Antimicrob Agents Chemother. 1990;342193- 2199
Link to Article
Naber  KGWitte  WBauernfeind  A  et al.  Clinical significance and spread of fluoroquinolone resistant uropathogens in hospitalised urological patients. Infection. 1994;22(suppl 2)S122- S127
Link to Article
Mabeck  CE Studies in urinary tract infections, IV: urinary leukocyte excretion in bacteriuria. Acta Med Scand. 1969;186193- 198
Link to Article
Stamm  WERunning  KMcKevitt  M  et al.  Treatment of the acute urethral syndrome. N Engl J Med. 1981;304956- 958
Link to Article
O'Grady  NPBarie  PSBartlett  J  et al.  Practice parameters for evaluating new fever in critically ill adult patients. Crit Care Med. 1998;26392- 408
Link to Article
Maki  DGKnasinski  VTambyah  PA A prospective investigator-blinded trial of a novel nitrofurazone-impregnated indwelling urinary catheter [abstract]. Infect Control Hosp Epidemiol. 1997;18(suppl)50Abstract M49.
Maki  DGKnasinski  VHalvorson  KTambyah  PA A novel silver-hydrogel–impregnated indwelling catheter reduces CAUTIs: a prospective double-blind trial.  Paper presented at: Society for Healthcare Epidemiology in America Annual Meeting April 5, 1998 Orlando, Fla.
Garibaldi  RABurke  JPDickman  MLSmith  CB Factors predisposing to bacteriuria during indwelling urethral catheterization. N Engl J Med. 1974;291215- 219
Link to Article
Platt  RPolk  BFMurdock  BRosner  B Risk factors for nosocomial urinary tract infection. Am J Epidemiol. 1986;124977- 985
Burke  JPRiley  DK Nosocomial urinary tract infections. Mayhall  CGed.Hospital Epidemiology and Infection Control. Philadelphia, Pa Lippincott Williams & Wilkins1996;139- 153
Stark  RPMaki  DG Bacteriuria in the catheterized patient: what quantitative level of bacteriuria is relevant? N Engl J Med. 1984;311560- 564
Link to Article
Balows  LEedHausler  WedShadomy  Hed Manual of Clinical Microbiology. 5th ed. Washington, DC American Society for Microbiology1991;
Stamm  WE Measurement of pyuria and its relation to bacteriuria. Am J Med. 1983;75(suppl 1B)53- 58
Link to Article
Tambyah  PAMaki  DG Catheter-associated urinary tract infection is rarely symptomatic: a prospective study of 1497 catheterized patients. Arch Intern Med. 2000;160678- 682
Brumfitt  W Urinary cell counts and their value. J Clin Pathol. 1965;18550- 555
Little  PJ Diagnostic criteria of pyelonephritis. J Clin Pathol. 1965;18556- 558
Hutt  MSRChalmers  JAMacDonald  JSdeWardener  HE Pyelonephritis: observations on the relation between various diagnostic procedures. Lancet. 1961;1351- 357
Link to Article
Gadeholt  H Quantitative estimation of cells in urine. Acta Med Scand. 1968;183369- 374
Link to Article
Warren  JWMobley  HLT Urinary Tract Infections: Molecular Pathogenesis and Clinical Management.  Washington, DC American Society for Microbiology Press1996;
Kaye  D Urinary Tract Infection and Its Management.  St Louis, Mo Mosby–Year Book Inc1972;
Stamm  WE Criteria for the diagnosis of urinary tract infection and for the assessment of therapeutic effectiveness. Infection. 1992;20(suppl 3)S151- S154
Link to Article
Peterson  JRRoth  EJ Fever, bacteriuria and pyuria in spinal cord injured patients with indwelling urethral catheters. Arch Phys Med Rehabil. 1989;70839- 841
Gribble  MJPuterman  MLMcCallum  NM Pyuria: its relationship to bacteriuria in spinal cord injured patients on intermittent catheterization. Arch Phys Med Rehabil. 1989;70376- 379
Musher  DMThorsteinsson  SBAirola  VM Quantitative urinalysis: diagnosing urinary tract infection in men. JAMA. 1976;2362069- 2072
Link to Article
Rimland  DAlexander  W Absence of factors associated with significant urinary tract infections caused by coagulase-negative staphylococci. Diagn Microbiol Infect Dis. 1989;12123- 127
Link to Article
Huang  CTLeu  HSKo  WC Pyuria and funguria. Lancet. 1995;346582- 583
Link to Article
Quintiliani  RCunha  BKlimek  JMaderazo  EG Bacteremia after manipulation of the urinary tract: the importance of pre-existing urinary tract disease and compromised host defences. Postgrad Med J. 1978;54668- 671
Link to Article
Wakabayashi  GGelfland  JAJung  WKConnolly  RJBurke  JFDinarello  CA Staphylococcus epidermidis induces complement activation, tumor necrosis factor and interleukin-1, a shock-like state and tissue injury in rabbits without endotoxemia: comparison to Escherichia coliJ Clin Invest. 1991;871925- 1935
Link to Article
Johnson  JR Virulence factors in Escherichia coli urinary tract infection. Clin Microbiol Rev. 1991;480- 128
Ulleryd  PLincoln  KScheutz  FSandberg  T Virulence characteristics of E coli in relation to host response in men with symptomatic urinary tract infection. Clin Infect Dis. 1994;18579- 584
Link to Article
Stamm  WEHooton  TMJohnson  JR  et al.  Urinary tract infections: from pathogenesis to treatment. J Infect Dis. 1989;159400- 406
Link to Article
Bronsema  DAAdams  JRPallares  RWenzel  RP Secular trends in rates and etiology of nosocomial urinary tract infections at a university hospital. J Urol. 1993;150414- 416
Little  PJ Urinary white cell excretion. Lancet. 1962;11149- 1151
Link to Article

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