|
|
|
| What is the prognosis of emphysematous pyelonephritis associated with extended-spectrum beta-lactamases producing microorganisms? |
José Iván Robles-Torres,Marco Alberto Ocaña-Munguía,José Gustavo Arrambide-Herrera,Adrián Mauricio Martínez-Fernández,Rodrigo Romero-Mata,Lauro Salvador Gómez-Guerra*( )
|
| Urology Department, Hospital Universitario “Dr. Jose´ Eleuterio Gonza´lez", Universidad Auto´noma de Nuevo Leon, Monterrey, Nuevo Leon, Mexico |
|
|
|
|
Abstract Objective: To describe the microbiological characteristics in emphysematous pyelonephritis (EPN), demonstrate the frequency of extended-spectrum beta-lactamase (ESBL) microorganisms, and determine if these microorganisms are associated with the prognosis of patients with EPN. Methods: We conducted a retrospective study in patients with a diagnosis of EPN in a tertiary care hospital of the northeast region of Mexico during the period from January 2011 to January 2016. Clinical variables were analyzed to determine association with the presence of ESBL-producing microorganisms. Statistical significance was set with p<0.05. Results: A total of 63 patients were included; 55 (87.3%) of them were females, with a median age of 55 (interquartile range: 45-65) years. Conservative management was indicated in 38.1%; 42.9% were treated with ureteral stent; 12.7% with open or percutaneous drainage; 15.8% with early nephrectomy; and 9.5% with delayed nephrectomy. Reported mortality was 13 (20.6%) cases; 23 (36.5%) cases required admission to the intensive care unit. The most frequent microorganism isolated was Escherichia coli (n=34, 53.9%). ESBL microorganisms were found in 31.7% of the population. No significant association of ESBL was found with admission to the intensive care unit, or with increased mortality. Conclusions: To our knowledge, this is the first study that evaluates ESBL microorganisms as a prognostic factor in EPN. Risk factors associated with a poor prognosis in patients with EPN have been described. The microbiological factors, specifically ESBL-producing bacteria, do not seem to influence in the prognosis of these patients.
|
|
Received: 23 September 2020
Available online: 20 April 2022
|
|
Corresponding Authors:
Lauro Salvador Gómez-Guerra
E-mail: laurogomez@hotmail.com
|
|
|
| Variable | Result | | Demographic | | Age, median (IQR), year | 55 (45-65) | | Female, n (%), year | 55 (87.3) | | Clinical presentation, n (%) | | Hemodynamic instabilitya | 24 (38.1) | | Fever (>38.3 °C) | 23 (36.5) | | Flank pain | 50 (79.4) | | Biochemistry, n (%) | | Leukocytosis (>11 000/μL) | 41 (65.1) | | Thrombocytopenia (<150 000/μL) | 15 (23.8) | | Renal failure (serum creatinine >1.2 mg/dL) | 36 (57.1) | | Hypoalbuminemia (<3.5 g/dL) | 34 (54.0) | | qSOFA (≥2 points), n (%) | 28 (44.4) | | Comorbidities, n (%) | | Diabetes mellitus | 56 (88.9) | | Arterial hypertension | 30 (47.6) | | Chronic kidney disease | 17 (27.0) | | Hydronephrosis | 23 (36.5) | | Urolithiasis | 21 (33.3) | | Previous antibioticb | 34 (54.0) | | Urine culture pathogens, n (%) | | E. coli | 20 (31.7) | | E. coli ESBL | 14 (22.2) | | Sterile culture | 9 (14.3) | | Candida spp. | 8 (12.7) | | Klebsiella spp. ESBL | 6 (9.5) | | Klebsiella spp. | 3 (4.8) | | Othersc | 3 (4.8) | | Huang scale, n (%) | | Type 1 | 34 (54.0) | | Type 2 | 8 (12.7) | | Type 3 (A and B) | 9 (14.3) | | Type 4 | 12 (19.0) | | Therapeutic managementd, n (%) | | Conservative | 24 (38.1) | | Ureteral stent | 27 (42.9) | | Percutaneous or open drainage | 8 (12.7) | | Early nephrectomy | 10 (15.9) | | Delayed nephrectomy | 6 (9.5) | | Clinical outcome, n (%) | | Mortality | 13 (20.6) | | Intensive care unit | 23 (36.5) |
|
|
Population sociodemographics, clinical, and microbiological characteristics in emphysematous pyelonephritis (n=63).
|
| Antibiotic | Susceptibility, n (%) | Resistance, n (%) | | Levofloxacin | 23 (50.0) | 23 (50.0) | | Ciprofloxacin | 17 (37.0) | 29 (63.0) | | Nitrofurantoin | 32 (69.6) | 14 (30.4) | | Cefuroxime | 11 (23.9) | 35 (76.1) | | Cefotaxime | 14 (30.4) | 32 (69.6) | | Ceftriaxone | 22 (47.8) | 24 (52.2) | | Ceftibuten | 22 (47.8) | 24 (52.2) | | Amikacin | 31 (67.4) | 15 (32.6) | | Gentamicin | 22 (47.8) | 24 (52.2) | | Ampicillin | 9 (19.6) | 37 (80.4) | | AMC | 10 (21.7) | 36 (78.3) | | TMP/SMX | 6 (13.0) | 40 (87.0) | | Colistin | 44 (95.7) | 2 (4.3) | | Fosfomycin | 37 (80.4) | 9 (19.6) | | Meropenem | 42 (91.3) | 4 (8.7) |
|
|
Antimicrobial susceptibility rates of uropathogens in patients with emphysematous pyelonephritis (n=46a).
|
| Variable | ESBL, n=20 (31.7%) | non-ESBL, n=43 (68.3%) | p-Value | OR (95% CI) | | Demographic | | Age, median (IQR), year | 63.5 (51-67.5) | 52 (44-61) | 0.053 | N/A | | Female, n (%) | 16 (80.0) | 39 (90.7) | 0.235 | 0.41 (0.091-1.844) | | Clinical data, n (%) | | Hemodynamic instabilitya | 6 (30.0) | 18 (41.9) | 0.367 | 0.595 (0.192-1.847) | | Fever (>38.3 °C) | 7 (35.0) | 16 (37.2) | 0.865 | 0.909 (0.300-2.75) | | Flank pain | 16 (80.0) | 34 (79.1) | 0.932 | 1.059 (0.283-3.960) | | Biochemistry, n (%) | | Leukocytosis (>11 000/μL) | 17 (85.0) | 24 (55.8) | 0.065 | 4.486 (1.143-17.602) | | Thrombocytopenia (<150 000/μL) | 4 (20.0) | 11 (25.6) | 0.628 | 0.727 (0.200-2.648) | | Renal injury (creatinine >1.2 mg/dL) | 11 (55.0) | 25 (58.1) | 0.815 | 0.880 (0.302-2.563) | | Hypoalbuminemia (<3.5 g/dL) | 9 (45.0) | 25 (58.1) | 0.330 | 0.589 (0.202-1.716) | | qSOFA (≥2 points), n (%) | 8 (40.0) | 20 (46.5) | 0.580 | 0.766 (0.261-2.250) | | Comorbidities, n (%) | | Diabetes mellitus | 17 (85.0) | 39 (90.7) | 0.503 | 0.581 (0.117-2.883) | | Arterial hypertension | 9 (45.0) | 21 (48.8) | 0.777 | 0.857 (0.296-2.486) | | Chronic kidney disease | 7 (35.0) | 10 (23.3) | 0.356 | 1.723 (0.539-5.503) | | Hydronephrosis | 8 (40.0) | 15 (34.9) | 0.695 | 1.244 (0.417-3.711) | | Urolithiasis | 6 (30.0) | 15 (34.9) | 0.702 | 0.800 (0.225-2.511) | | Previous antibioticb | 9 (45.0) | 25 (58.1) | 0.330 | 0.589 (0.202-1.716) | | Huang scale, n (%) | | Type 1 | 10 (50.0) | 24 (55.8) | 0.731 | 0.791 (0.273-2.292) | | Type 2 | 1 (10.0) | 7 (16.3) | 0.206 | 0.270 (0.030-2.365) | | Type 3 (A and B) | 4 (20.0) | 5 (11.6) | 0.406 | 1.900 (0.450-8.008) | | Type 4 | 5 (25.0) | 7 (16.3) | 0.446 | 1.714 (0.469-6.265) | | Gas formation in kidney (>50% renal parenchyma), n (%) | 9 (45.0) | 12 (27.9) | 0.180 | 2.114 (0.700-6.379) | | Therapeutic managementc, n (%) | | Conservative | 7 (35.0) | 17 (39.5) | 0.730 | 0.824 (0.273-2.483) | | Ureteral stent | 9 (45.0) | 18 (41.9) | 0.815 | 1.136 (0.390-3.310) | | Percutaneous or open drainage | 4 (20.0) | 4 (9.3) | 0.235 | 2.438 (0.542-10.958) | | Early nephrectomy | 1 (10.0) | 9 (20.9) | 0.103 | 0.198 (0.023-1.691) | | Delayed nephrectomy | 4 (20.0) | 2 (4.7) | 0.053 | 5.125 (0.853-20.788) | | Clinical outcome, n (%) | | ICU | 9 (45.0) | 14 (32.6) | 0.374 | 1.636 (0.550-4.866) | | Mortality | 6 (30.0) | 7 (16.3) | 0.228 | 2.143 (0.611-7.511) |
|
|
Comparison of demographic, clinical and prognostic factors between patients with emphysematous pyelonephritis caused by ESBL-producing agents and non-ESBL agents (n=63).
|
| [1] |
Michaeli J, Mogle P, Perlberg S, Heiman S, Caine M. Emphysematous pyelonephritis. J Urol 1984; 131:203-8.
doi: 10.1016/s0022-5347(17)50309-2
pmid: 6366247
|
| [2] |
Pontin AR, Barnes RD, Joffe J, Kahn D. Emphysematous pyelonephritis in diabetic patients. Br J Urol 1995; 75:71-4.
pmid: 7850302
|
| [3] |
Ubee SS, McGlynn L, Fordham M. Emphysematous pyelonephritis. BJU Int 2011; 107:1474-8.
doi: 10.1111/j.1464-410X.2010.09660.x
|
| [4] |
Kumar A, Turney JH, Brownjohn AM, McMahon MJ. Unusual bacterial infections of the urinary tract in diabetic patientsdrare but frequently lethal. Nephrol Dial Transplant 2001; 16:1062-5.
doi: 10.1093/ndt/16.5.1062
|
| [5] |
Huang JJ, Tseng CC. Emphysematous pyelonephritis: Clinicoradiological classification, management, prognosis, and pathogenesis. Arch Intern Med 2000; 160:797-805.
pmid: 10737279
|
| [6] |
Falagas ME, Alexiou VG, Giannopoulou KP, Siempos II. Risk factors for mortality in patients with emphysematous pyelonephritis: A meta-analysis. J Urol 2007; 178:880-5.
doi: 10.1016/j.juro.2007.05.017
|
| [7] |
Huang JJ, Chen KW, Ruann MK. Mixed acid fermentation of glucose as a mechanism of emphysematous urinary tract infection. J Urol 1991; 146:148-51.
doi: 10.1016/s0022-5347(17)37736-4
pmid: 2056576
|
| [8] |
Tseng CC, Wu JJ, Wang MC, Hor LI, Ko YH, Huang JJ. Host and bacterial virulence factors predisposing to emphysematous pyelonephritis. Am J Kidney Dis 2005; 46:432-9.
doi: 10.1053/j.ajkd.2005.05.019
|
| [9] |
Robles-Torres JI, Ocaa-Munguía MA, Madero-Morales PA, Ruíz- Galindo E, Gámez-Guerra L. Antimicrobial resistance and extended spectrum beta-lactamases in urinary tract infections: A serious problem in Northern Mexico. Urology 2020; 80:1-12.
doi: 10.1016/j.urology.2012.03.032
|
| [10] |
Olvera-Posada D, Armengod-Fischer G, Vázquez-Lavista LG, Maldonado-Ávila M, Rosas-Nava E, Manzanilla-García H, et al. Emphysematous pyelonephritis: Multicenter clinical and therapeutic experience in Mexico. Urology 2014; 83: 1280-4.
doi: 10.1016/j.urology.2014.02.010
pmid: 24726310
|
| [11] |
Weinstein MP, Lewis II JS, Bobenchik AM, Campeau S, Cullen SK, Galas MF, et al. Performance standards for antimicrobial susceptibility testing. 31th ed. Wayne, Pennsylvania: Clinical and Laboratory Standards Institute; 2021. p. 29-50.
|
| [12] |
Aswathaman K, Gopalakrishnan G, Gnanaraj L, Chacko NK, Kekre NS, Devasia A, et al. Emphysematous pyelonephritis: Outcome of conservative management. Urology 2008; 71: 1007-9.
doi: 10.1016/j.urology.2007.12.095
|
| [13] |
Somani BK, Nabi G, Thorpe P, Hussey J, Cook J, N’Dow J, et al. Is percutaneous drainage the new gold standard in the management of emphysematous pyelonephritis? Evidence from a systematic review. J Urol 2008; 179:1844-9.
doi: 10.1016/j.juro.2008.01.019
|
| [14] |
Lu YC, Hong JH, Chiang BJ, Pong YH, Hsueh PR, Huang CY, et al. Recommended initial antimicrobial therapy for emphysematous pyelonephritis: 51 cases and 14-year-experience of a tertiary referral center. Medicine 2016; 95:-3573. https://doi.org/10.1097/MD.0000000000003573.
|
| [15] |
Sokhal AK, Kumar M, Purkait B, Jhanwar A, Singh K, Bansal A, et al. Emphysematous pyelonephritis: Changing trend of clinical spectrum, pathogenesis, management and outcome. Turk J Urol 2017; 43:202-9.
doi: 10.5152/tud.2016.14227
pmid: 28717547
|
| [16] |
Parret AH, De Mot R. Escherichia coli’s uropathogenic-specific protein: A bacteriocin promoting infectivity?. Microbiology 2002; 148:1604-6.
doi: 10.1099/00221287-148-6-1604
|
| [17] |
Tseng CC, Huang JJ, Ko WC, Yan JJ, Wu JJ. Decreased predominance of papG class II allele in Escherichia coli strains isolated from adults with acute pyelonephritis and urinary tract abnormalities. J Urol 2001; 166:1643-6.
pmid: 11586193
|
| [18] |
Kapoor R, Muruganandham K, Gulia AK, Singla M, Agrawal S, Mandhani A, et al. Predictive factors for mortality and need for nephrectomy in patients with emphysematous pyelonephritis. BJU Int 2010; 105:986-9.
doi: 10.1111/j.1464-410X.2009.08930.x
|
| [19] |
Olvera-Posada D, García-Mora A, Culebro-García C, Castillejos- Molina R, Sotomayor M, Feria-Bernal G, et al. Prognostic factors in emphysematous pyelonephritis. Actas Urol Esp 2013; 37:228-32.
doi: 10.1016/j.acuro.2012.03.021
pmid: 23260183
|
| [20] |
Jain A, Manikandan R, Dorairajan LN, Sreenivasan SK, Bokka S. Emphysematous pyelonephritis: Does a standard management algorithm and a prognostic scoring model optimize patient outcomes? Urol Ann 2019; 11:414-20.
doi: 10.4103/UA.UA_17_19
|
| [21] |
Kuzgunbay B, Turunc T, Tokmak N, Turunc T, Dirim A, Aygun C, et al. Tailored treatment approach for emphysematous pyelonephritis. Urol Int 2011; 86:444-7.
doi: 10.1159/000323604
pmid: 21508616
|
| [1] |
Mengzhu Liu,Kun Jin,Shi Qiu,Pengyong Xu,Mingming Zhang,Wufeng Cai,Xiaonan Zheng,Lu Yang,Qiang Wei. Oncological outcomes of patients with ductal adenocarcinoma of the prostate receiving radical prostatectomy or radiotherapy[J]. Asian Journal of Urology, 2021, 8(2): 227-234. |
|
|
|
|
