in institutionalized e lderly subjects. Can J Infe ct Dis 199 1;2(4 ):142-146. Two hundred and forty-three wine specimens from 76 elderly institutionalized residents were obtained for urine culture, quantitative leukocyte count and winalysis. Significant bacteriuria was present in 153 specimens (63%), including 33 (22%) with more than one organism. Pyuria (greater than or equal to 10 leukocytes/mm3 ) was present in 214 specimens (88%). including 116 (97%) with single organism bacteriuria, 27 (82%) with multiple organism bacteriuria, and 71 (80%) without significant bacteriuria. The leukocyte esterase test had a positive predictive value of 99% for pyuria but a negative predictive value of only 30%. The quantitative level of pyuria was associated with the level of proteinuria and inversely with pH. A relatively constant level of pyuria tended to persist over months to years in a given individual if bacteriuria persisted. Pyuria is significantly associated with bacteriuria in the institutionalized elderly, but is also common in the nonbacteriuric. The clinical significance of pyuria requires further assessment. (3,5,6), and is highest in the most disabled. In the absence of a chronic indwelling catheter, bacteriuria is associated with relatively low morbidity, and treatment with antibiotics is followed by early recurrence (1,2). It has been suggested, however, that the presence of pyuria in individuals with bacteriuria is an indicator of infection of the urinary tract rather than 'colonization', and that pyuria is an indication for therapy. The validity of treatment decisions based on the presence or absence of pyuria has not been reported.This study was undertaken to determine some of the characteristics of pyuria in a group of institutionalized elderly subjects. The association of pyuria with bacteriuria and other urinary characteristics including pH, protein and glucose measurements, type of infecting organism, and the leukocyte esterase test were examined. Some observations on the natural history of pyuria are also reported, including degree of variability in the same individual over time. PATIENTS AND METHODS Patient population:The population studied included 57 males and 19 females, 32% of the 239 permanent residents of the Deer Lodge Centre, an extended care facility in Winnipeg, Manitoba. The mean age was 80 years (range 50 to 95). All participants had a high level of functional disability. Urine specimens were collected from a convenience sample of residents for a study characterizing some features of asymptomatic bacteriuria in this population. Nursing staff collected specimens from one individual whom they felt had bacteriuria based on a subjective assessment of smell and cloudiness, and from a second individual on the same ward whom they thought did not have infection. Residents with symptomatic bacteriuria characterized by symptoms of dysuria, frequency, urgency, hematuria, acute alteration in continence status, suprapubic discomfort, or signs of epididymo-orchitis or bacteremia, were excluded. Micro...

OBJECTIVE:To monitor prospectively patients with Clostridium difficile-associated diarrhea (CAD) in a six hundred bed tertiary care hospital to determine which factors influenced the recurrence of the diarrhea. DESIGN: A prospective, nonrandomized study. After an initial diagnosis of CAD, patients were interviewed, and each week stool samples and environmental samples were monitored for the presence of toxigenic C difficile for as long as the patients remained in hospital. The relationship of concurrent antibiotics, prolonged fecal excretion of organism or toxin, and environmental contamination was assessed. PATIENTS: Over a two-and-a-half year period, 75 consecutive patients with CAD were selected and those who gave their written informed consent were enrolled. A control group to evaluate environmental contamination consisted of 75 patients with diarrhea not associated with C difficile. RESULTS: Of the 75 CAD patients, 11 (14.7%) had a recurrence of their diarrhea. Diarrhea recurrence was associated with an increased rate of prolonged excretion of toxigenic organism and/or C difficile toxin(s) (nine of 11 [81.8%] compared with nine of 64 [14.1%]; P£ 0.0001; relative risk 14.25; 95% CI 3.383 to 60.023). The risk of diarrhea recurrence was not related to a specific antibiotic but to concurrent therapy. Treatment within 30 days of initial CAD-specific treatment with an antibiotic other than metronidazole or vancomycin occurred significantly more frequently in patients with recurrence of diarrhea compared with those who did not have a recurrence (eight of 11 [72.7%] Pour voir le résumé, voir page suivante C lostridium difficile is the most commonly known etiological agent of hospital-acquired infectious diarrhea (1-7). Only strains that produce both toxin A and toxin B have been associated with human disease (7)(8)(9)(10)(11)(12)(13)(14)(15)(16). Approximately 15% (range of 5% to 24%) of patients who are treated for C difficile-associated diarrhea have a recurrence of their diarrhea (17)(18)(19); this may be due to relapse with their original C difficile strain or due to reinfection with a different strain (20). The basis for the recurrence of diarrhea and the role of prolonged fecal excretion of toxin in the risk of diarrhea recurrence have not been well studied. The aims of this study were to follow prospectively 75 patients with C difficile-associated diarrhea (CAD), and determine the frequency and temporal distribution of diarrhea recurrence; determine whether factors such as concurrent antibiotics, or continued excretion of C difficile toxin(s) or toxigenic organisms in patients treated for CAD correlated with diarrhea recurrence; and determine the frequency of environmental contamination and the relationship of environmental isolates to patient isolates. PATIENTS AND METHODS Patient populations studied:Inpatients of St Boniface General Hospital, St Boniface, Manitoba, with diarrhea, whose stool samples had been tested for C difficile cytotoxin, were reviewed on a daily basis. The routine CAD diagnostic test...

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