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Changing treatment patterns in urinary infections.

IN 1983 a panel was assembled to provide an overview of our understanding of the pathogenesis, diagnosis, treatment, and prevention of urinary tract infections. ' Specifically, natural host defenses that function during normal physiologic conditions to prevent the development of urinary infections were emphasized, as were the intrinsic risk factors that alter normal host defenses.2 Intrinsic risk factors were identified as: urinary tract obstruc-tion, stasis, and reflux; pregnancy and old age; sexual intercourse in women; people with B or AB type blood; hyperosmolality of the renal medulla which inhibits mobilization of granulocytes into the injured medulla and decreases their ability to phagocytose bacteria; differences in bladder and kidney host cell receptor sites for uropathic bacteria; possibly increased receptivity of uroepithelial, periurethral, and vaginal cells for uropathic coliforms in some patients with recurrent urinary tract infections; and immunologic mechanisms related to the persistence of bacterial antigen and to cross-reactivity between Tamm-Horsfall protein and Gram-negative bacteria which may con-tribute to renal damage. We learned that instrumentation of the tract is the major extrinsic risk responsible for urinary tract infections, and that indwelling urinary catheters continued to be the leading cause of nosocomial urinary tract infections and the most common predisposing factor in fatal Gram-negative sepsis in hospitals.3