OBJECTIVE: To review current knowledge relevant to complicated urinary tract infection, and to provide evidence-based recommendations for management. METHODS: The literature was reviewed through a PubMed search, and additional articles were identified by journal reference review. A draft guideline was prepared and critically reviewed by members of the Association of Medical Microbiology and Infectious Disease Canada Guidelines Committee, with modifications incorporated following the review. RESULTS: Many urological abnormalities may be associated with complicated urinary infection. There is a wide spectrum of potential infecting organisms, and isolated bacteria tend to be more resistant to antimicrobial therapy. Morbidity and infection outcomes in subjects with complicated urinary infection are principally determined by the underlying abnormality rather than the infection. Principles of management include uniform collection of a urine specimen for culture before antimicrobial therapy, characterization of the underlying genitourinary abnormality, and nontreatment of asymptomatic bacteriuria except before an invasive genitourinary procedure. The antimicrobial regimen is determined by clinical presentation, patient tolerance, renal function and known or anticipated infecting organisms. If the underlying abnormality contributing to the urinary infection cannot be corrected, then early post-treatment recurrence of infection is anticipated. CONCLUSIONS: The management of complicated urinary infection is individualized depending on patient variables and the infecting organism. Further clinical investigations are necessary to assist in determining optimal antimicrobial regimens.

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The results of the present study showed that serological evidence of HEV infection was present in 3% of the observed Canadian Inuit population; the presence of IgM anti-HEV suggested recent infection and HEV did not appear to coinfect with other common hepatotropic viruses. The source of HEV infection in the population remains unclear. These findings are interesting but preliminary. Additional data are required to determine whether HEV infections are responsible for otherwise unexplained acute hepatitis in the Canadian Inuit population and visitors returning from northern North American communities.

We determined the validity of using external devices for urine specimen collection from 24 elderly incontinent men residing in a nursing home by collecting three sequential specimens, two with external devices and then one by catheterization. The positive predictive value of organisms isolated in quantitative counts of 2105 CFU/ml in external devices for bladder bacteriuria was 86% for either sterile or clean collecting devices and 93% for the same organism in two consecutive specimens. The negative predictive value for organisms present in quantitative counts of <105 CFU/ml was 90% for both sterile and clean devices and 86% when the organism was present in both specimens. Contamination in external collection devices was not influenced by whether the device was clean or sterile, circumcision of the resident, or duration of time between device application and specimen collection. These data suggest that urine specimens collected by ward nursing staff with external devices are reliable for the diagnosis of bacteriuria in this patient population.Incontinence is a common problem in elderly men residing in nursing homes (5, 10). Collection of valid clean-catch urine specimens for culture from such individuals is frequently difficult or impossible due to lack of voiding control or lack of cooperation. For many of these residents, incontinence is managed through the use of condom drainage and leg bags (10). When urine specimens for culture are required, specimens are sometimes collected from these external drainage devices (1). This method of specimen collection may lead to contamination with flora colonizing the glans penis, compromising the validity of such specimens (2). Thus, it has been suggested that only specimens collected by in-and-out catheter, an invasive method, may be valid for this population.Bacteriuria has a prevalence approaching 50% in elderly institutionalized men (6,8). Studies to clarify the pathogenesis, natural history, and therapeutic outcome of bacteriuria in this population require a reliable, noninvasive method for the collection of urine specimens. Recently, Ouslander et al. (9) examined the reliability of urine specimens collected with external devices and reported that specimens collected by a single study nurse using a standard protocol were valid for mnicrobiologic analysis. We report here our observations of the validity of such specimen collection where specimens were collected by the ward nursing staff. In addition, factors which might correlate with contamination and the presence of pyuria in specimens were examined.(This study was presented in part at the 26th Interscience Conference on Antimicrobial Agents and Chemotherapy, New Orleans, La., September 1986.) MATERIALS AND METHODS Patient population. The study subjects were 24 elderly men with incontinence who reside at the Deer Lodge Centre, Winnipeg, Manitoba. Fourteen of these had incontinence managed by chronic condom drainage. Characteristics of * Corresponding author. this study population have been previously described (8). T...

Candida species infections are the major pathogens in invasive fungal infections in Canada; all other species occur relatively infrequently. The potential for therapeutic intervention to limit mortality requires further assessment.

A methicillin-resistant Staphylococcus aureus (MRSA) strain introduced into the largest tertiary-care teaching hospital in Manitoba in 1993 led to a sustained outbreak with secondary outbreaks at one community hospital, two large long-term-care facilities, and nosocomial transmission at a second teaching hospital. Control measures were consistent at each institution and were coordinated on a province-wide basis. MRSA is not currently endemic in any facility in the province.

Infect Dis 1 994; 5(3):130-132. Episodes of bacteremia identified in a long term care facility over a seven and a half-year period from July 1984 lo December 1991 were reviewed. 1\venly-nine episodes of bacteremia were identified. a rate of 4.35/100.000 patient-days. The most common infecting organisms were Escherichia coli (11 episodes) . Streptococcus pneumoniae (four). Proteus mirabilis (lhree). Staphy lococcus aureus (lhree) and Bacteroides species (two). The source of bacteremia was urimuy in 45o/o of patients. gastrointestinal in 17o/o, pneumonia in 14o/o, skin in 14o/o and unknown in 1 Oo/o. The overall case fa tali ly rate was 24o/o. bu l for lhe final six years of the review lhe case fatality rate was only 9 .5o/o. These observations report a rate of bacteremia 10-fold lower lhan reported from olher Norlh American long term care facilities and. potentially. a lower case fatality rate. The primary site of bacteremia. however. in long term care faci lities is U1e w·inary tract. R ESIDENTS OF LONG TERM CARE FACILITIES ARE ATincreased risk for infection because of associated comorbidities, interventions n ecessitated by chronic functional problems and, possib ly, because of institutionalization. Bacteremia is an important infection because it is generally associated with a high mortality. There is limited information available, however, that describes bacteremia occurring in long term care facilities. Studies reporting bacteremia in long term care facilities in the United States have identified urinary t ract infection as the most frequent source, and reported an incidence of about 0.3/1000 patient-days (1-3). The overall mortality has been 21 to 35%. The present study of bacteremia occurring in one long term care facility in Winnipeg, Manitoba over a seven and a half-year period was undertaken to exan1ine characteristics of bacteremia in the study population and to compare this experience with that reported from other facilities in North America. PATIENT AND METHODS Institution:The Deer Lodge Centre is a long term care facility that was formerly a Veteran's Hospital. Most residents are male, with a male: female ratio of approximately 3.5: 1. During the period of this review, from July 1984 to December 1991, the centre varied in size from 199 to 420 beds. The remain ing acute care beds in the facility were progressively eliminated during this period and replaced by beds for assessment and rehabilitation. short term respite admissions and further long term care beds. This review describes bacteremia in permanent resid ents in the long term care facility beds at this institution. Residents who became acutely ill were transferred to the acute care ward in the facility where parenteral therapy and more intensive nursing care could be provided. They were not transferred to an acute care facility unless specialized intervention such as surgery was required . 'Death not directly attributed to infection be due to infection if the resident was clinically not anticipated to die within the short term and no cause ...

We determined the site of urinary tract infection in 51 elderly, institutionalized women (mean age, 80.5 years) with asymptomatic bacteriuria by using the Fairley bladder washout technique. Thirty-four (67%) infections were localized in the kidney and 17 (33%) in the bladder. Women with renal infection were older than those with bladder infection (81.9 vs. 77.6 years of age; P = .04). The antibody-coated bacteria test had a sensitivity of 58%, specificity of 71%, positive predictive value of 82%, and negative predictive value of 43% for upper-urinary-tract infection. A quantitative urinary leukocyte count of greater than or equal to 20 leukocytes/mm3 had a positive predictive value of 80% and a negative predictive value of 88% for upper-urinary-tract infection. This study suggests that the majority of elderly, institutionalized women with asymptomatic bacteriuria have upper-urinary-tract infection. Both the antibody-coated bacteria test and the quantitative urinary leukocyte count may be useful as noninvasive tests for localization of urinary tract infection in this population.