How would you answer these 7 most popular clinical questions of 2022 on Pearls4Peers??

Peers,

www.Pearls4Peers.com just turned 7 with 2022 poised to become its best year ever in viewership  (>30,000 views so far)!  To mark this “momentous” occasion, I thought I would share with you, loyal viewers and subscribers, the 7 most viewed posts  of 2022 at its midway point.  Imagine rounding on the wards with your team and someone asks you one or more of these questions.  Take a crack at answering them and compare your answers with those of P4P (Ctrl+Click)! Have fun!

  1. What is the significance of teardrop cells(dacrocytes) on the peripheral smear of my patient with newly-discovered pancytopenia?
  2.  My elderly patient developed a flare-up of her gout few days after receiving covid-19 vaccine. Is there a connection between immunization and gout flare? 
  3. What is the clinical relevance of the “SPICE” organisms? 
  4. What does an “indeterminate” result in QuantiFERON Gold in-Tube Test for latent tuberculosis really mean? 
  5. What is the difference between “moderate” and “high complexity” medical decision making under the Centers for Medicare and Medicaid Services (CMS) rule? 
  6. The urine culture of my female patient with urgency is growing Lactobacillus. Should I treat it?
  7. Why is serum AST levels generally higher than ALT in alcohol-induced liver injury?

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Disclosures: The listed questions and answers are solely the responsibility of the author and do not necessarily represent the official views of Mercy Hospital-St. Louis, Massachusetts General Hospital, Harvard Catalyst, Harvard University, their affiliate academic healthcare centers, or its contributors. Although every effort has been made to provide accurate information, the author is far from being perfect. The reader is urged to verify the content of the material with other sources as deemed appropriate and exercise clinical judgment in the interpretation and application of the information provided herein. No responsibility for an adverse outcome or guarantees for a favorable clinical result is assumed by the author. Thank you!

How would you answer these 7 most popular clinical questions of 2022 on Pearls4Peers??

The urine culture of my female patient with urgency is growing Lactobacillus spp.  Should I treat it?

Lactobacillus spp. isolated from urine generally do not require treatment because these organisms are often part of the normal bacterial flora of the genitourinary (GU) and gastrointestinal tracts, are generally of low virulence, are rarely associated with urinary tract infections (UTIs) and may in fact have potential benefits in preventing UTIs. 1-4

In a study involving female urinary microbiome, subjects with urgency urinary incontinence were less likely to have Lactobacillus spp. based on 16S rRNA gene sequencing of transurethral catheter urine than those without symptoms, suggestive of possible protective role of this organism in female GU tract.1

Reports of Lactobacillus UTI are rare but one particular species, Lactobacillus delbrueckii, has been implicated in several case reports involving primarily elderly women.3,4

Vaginal colonization with lactobacilli provides a natural, nonspecific defense mechanism against infection in part by production of lactic acid and lowering of the regional pH which, when combined with hydrogen peroxide production by commensal anaerobes, interferes with colonization of the vaginal mucosal surfaces by potential pathogens. Lactobacilli also interfere with the adherence of pathogens by production of biosurfactants.3

It’s no surprise that lactobacilli are often considered “friendly bugs” and used in many probiotic preparations as well.5

Bonus Pearl: Did you know that contrary to the current dogma, urine is not sterile when tested by more sensitive enhanced urine culture or gene sequencing techniques?  Even in asymptomatic people, it may contain several organisms, including Lactobacillus, Gardnerella, Streptococcus, Staphylococcus (not aureus) and Corynebacterium? 2

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References

  1. Pearce MM, Hilt EE, Rosenfeld AM, et al. The female urinary microbiome: a comparison of women with and without urgency urinary incontinence. mBio 2014;5:e01283-14. https://pubmed.ncbi.nlm.nih.gov/25006228/
  2. Thomas-White K, Forster SC, Kumar N, et al. Culturing of female bladder bacteria reveals an interconnected urogenital microbiota. Nature Communications 2018;9:1557. https://www.nature.com/articles/s41467-018-03968-5.pdf (urine not sterile, bladder with lactobacillus prevention, normal asymptomatic
  3. Darbro BW, Petroelje BK, Doern GV. Lactobacillus delbureckii as the cause of urinary tract infection. J Clin Microbiol 2009;47:275-277. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2620876/#:~:text=Urinary%20tract%20infections%20caused%20by,a%20setting%20of%20ureteral%20obstruction.
  4. Maillet F, Passeron A, Podglajen I, et al. Lactobacillus delbrueckii urinary tract infection in a male patient. Med Mal Infect 2019;49:225-230. https://www.sciencedirect.com/science/article/pii/S0399077X1830787X?via%3Dihub
  5. Reid G. The scientific basis for probiotic strains of Lactobacillus. App Env Microbiol 1999;65:3763-3766. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC99697/ 

 

Disclosures: The listed questions and answers are solely the responsibility of the author and do not necessarily represent the official views of Mercy Hospital-St. Louis or its affiliate healthcare centers, Mass General Hospital, Harvard Medical School or its affiliated institutions. Although every effort has been made to provide accurate information, the author is far from being perfect. The reader is urged to verify the content of the material with other sources as deemed appropriate and exercise clinical judgment in the interpretation and application of the information provided herein. No responsibility for an adverse outcome or guarantees for a favorable clinical result is assumed by the author. Thank you!

The urine culture of my female patient with urgency is growing Lactobacillus spp.  Should I treat it?