Asymptomatic bacteriuria: Difference between revisions

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The quantitative definition for significant bacteriuria is:<ref name="pmid1477233">{{cite journal| author=Rubin RH, Shapiro ED, Andriole VT, Davis RJ, Stamm WE| title=Evaluation of new anti-infective drugs for the treatment of urinary tract infection. Infectious Diseases Society of America and the Food and Drug Administration. | journal=Clin Infect Dis | year= 1992 | volume= 15 Suppl 1 | issue=  | pages= S216-27 | pmid=1477233 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1477233 }}</ref>
The quantitative definition for significant bacteriuria is:<ref name="pmid1477233">{{cite journal| author=Rubin RH, Shapiro ED, Andriole VT, Davis RJ, Stamm WE| title=Evaluation of new anti-infective drugs for the treatment of urinary tract infection. Infectious Diseases Society of America and the Food and Drug Administration. | journal=Clin Infect Dis | year= 1992 | volume= 15 Suppl 1 | issue=  | pages= S216-27 | pmid=1477233 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1477233 }}</ref>


* For asymptomatic women, bacteriuria is defined as 2 consecutive voided urine specimens with isolation of the same bacterial strain in quantitative counts of ≥10<sup>5</sup> [[cfu]]/mL.
* For asymptomatic women, bacteriuria is defined as 2 consecutive voided urine specimens with isolation of the same bacterial strain in quantitative counts of ≥10<sup>5</sup> [[Colony-forming unit|CFU]]/mL.


* A single, clean-catch, voided urine specimen with 1 bacterial species isolated in a quantitative count of ≥10<sup>5</sup> [[cfu]]/mL identifies bacteriuria in asymptomatic men.
* A single, clean-catch, voided urine specimen with 1 bacterial species isolated in a quantitative count of ≥10<sup>5</sup> [[Colony-forming unit|CFU]]/mL identifies bacteriuria in asymptomatic men.


* A single catheterized urine specimen with 1 bacterial species isolated in a quantitative count of ≥10<sup>2</sup> [[cfu]]/mL identifies bacteriuria in women or men.
* A single catheterized urine specimen with 1 bacterial species isolated in a quantitative count of ≥10<sup>2</sup> [[Colony-forming unit|CFU]]/mL identifies bacteriuria in women or men.


==Presumptive Etiologies==
==Presumptive Etiologies==

Revision as of 18:10, 15 January 2014

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Abdurahman Khalil, M.D. [2]

Overview

Asymptomatic bacteriuria is a condition in which a significant number of bacteria appear in the urine occurring without typical symptoms such as burning during urination or frequent urination.[1]

Definitions

Asymptomatic bacteriuria is defined as isolation of a specified quantitative count of bacteria in an appropriately collected urine specimen obtained from a person without symptoms or signs referable to urinary infection.[2]

Historical Perspective

In 1950s, Kass et al. proposed a quantitative culture method for the microbiologic diagnosis of urinary tract infections. About 105 bacteria per milliliter must be present in the urine specimen to be consistently read as positive, which is seen in 95% of samples from patients with pyelonephritis.[3][4]

Epidemiology

Bacteriuria is commonly found in certain populations with variable prevalence including pregnant women,[5] elderly people,[5] diabetics,[6] patients with spinal cord injuries,[7][8] patients undergoing hemodialysis,[9] patients with indwelling urethral catheters, and patients with genitourinary abnormalities.[10]

Pathophysiology

Microbiology

Host Factors

Screening

Screening for asymptomatic subjects is deemed appropriate if bacteriuria is associated with preventable adverse outcomes such as symptomatic urinary infection, progression to chronic kidney disease or hypertension, development of urinary tract cancer, and decreased duration of survival.[11]

Diagnosis

Laboratory Findings

Pyuria

Pyuria is defined as increased numbers of polymorphonuclear leukocytes in the uirne and is evidence of an inflammatory response in the urinary tract.[12] An operational definition of pyuria is the presence of ≥15 leukocytes per 400x microscopic field in the sediment of first-void urine. Although pyuria is prevalent among people with asympatomatic bacteriuria,[7][13][14][15][16] its presence or degree has not been shown to correlate with the prognosis and should not affect clinical decisions about antibiotics.[17][18][19] Pyuria accompanying asymptomatic bacteriuria is not an indication for antimicrobial treatment.[11]

Diagnostic Criteria

The diagnosis of bacteriuria in an asymptomatic individual is based on the culture results of urine collected in a manner that minimizes the possibility of contamination and limits the period between sampling and testing the specimen to avoid false positivity due to bacterial growth.

The quantitative definition for significant bacteriuria is:[20]

  • For asymptomatic women, bacteriuria is defined as 2 consecutive voided urine specimens with isolation of the same bacterial strain in quantitative counts of ≥105 CFU/mL.
  • A single, clean-catch, voided urine specimen with 1 bacterial species isolated in a quantitative count of ≥105 CFU/mL identifies bacteriuria in asymptomatic men.
  • A single catheterized urine specimen with 1 bacterial species isolated in a quantitative count of ≥102 CFU/mL identifies bacteriuria in women or men.

Presumptive Etiologies

Most common organism

Escherichia coli is the single most common cause of asymptomatic bacteriuria.[21] [22] [23]

Patients with abnormal genitourinary tract or institutionalized elderly:
E.Coli remain common cause, but in men Proteus mirabilis is more common.[24]

Long term urologic device in place
Polymicrobial including Pseudomonas aeruginosa,P. mirabilis, Providencia stuartii, and Morganella morganii (urease-producing organisms).[24] [25]

Other organisms

Treatment

Premenopausal, Nonpregnant Women

No screening or treatment recommended for healthy, bacteriuric women.
Although asymptomatic bacteriuria increases the risk of urinary tract infection but has no effect on the long term adverse outcomes like CKD, genitourinary cancer or overall survival.[28] [23] Studies' results indicated that the treatment wouldn't decrease the frequency for asymptomatic bacteriuria or the risk of developing symptomatic urinary tract infection.[29]

Pregnant Women

Pregnant women
Regimen:3-7 day for any of the following
▸ Amoxicillin 250 mg–1 gm po tid
OR
Oral cephalosporins
Cefaclor500 mg po q8h or 500 mg extended release q12h
Cefdinir 300 mg po q12h or 600 mg po q24h
Cefditoren 200 mg tabs—2 tabs bid
Cefixime 400 mg po q24h
Cefpodoxime proxetil 200 mg po q12h
Cefprozil 500 mg po q12h
Ceftibuten 400 mg po q24h
Cefuroxime axetil 250 or 500 mg q12h
Loracarbef 400 mg po q12h
OR
▸ TMP-SMX DS 1 tab bid
OR
▸ Trimethoprim 100 mg po q12h or 200 mg po q24h.


In early pregnancy, both screening for asymptomatic bacteriuria by urine culture and treatment of positive results are recommended.

  • Single screening with urine culture[30]in the first trimester[31]proved to be effective.[32]
  • Antibiotics treatment has shown a significant decrease in the risk of subsequent pyelonephritis(from 25-30% to 1-4%).[33] It also reduce the frequency of preterm deliveries and low birth weight.[34] [35]
  • The duration of antimicrobial therapy is 3-7 days.
  • After therapy of recurrent bacteriuria, periodic screening should be considered.

Diabetic Women

Asymptomatic bacteriuria screening or treatment is not recommended for diabetic women.

  • No change in the rate of symptomatic urinary tract infection, diabetes progression and complication or overall mortality in diabetic women[36] [37], in addition to the adverse effects of antimicrobial therapy.[18]

Older Persons Residing in the Community

Routine screening and treatment for asymptomatic bacteriuria is not indicated.

  • Treatment has no effect on decreasing symptomatic urinary tract infections,[38] adverse outcomes or survival.[39] [40]

Elderly Institutionalized Subjects

No recommendation for screening for or treatment of asymptomatic bacteriuria.

  • No reduction in rates of symptomatic infections or survival.[41] [42]
  • Instead, treatment has increased the risk of adverse effects and reinfections with resistant strains.[41]

Subjects with Spinal Cord Injuries

No benefit from screening for or treatment of asymptomatic bacteriuria Although the high prevalence of asymptomatic bacteriuria in patients with spinal cord injuries[43], but antimicrobial therapy harm outweigh benefit because of recurrent infections with more resistant strains.[8]

Patients with Indwelling Urethral Catheters

It is not recommended to screen for or treat asymptomatic bacteriuria or fungiuria for short or long term catheters,[44] but antimicrobial therapy can be used for women with persistent bacteriuria 48 hours after removal of the urethral catheter.

  • No benefit of therapy of asymptomatic bacteriuria due to similar recurrence rates with more resistance to antibiotics.[45][46]
  • Significant improvement has been shown with women treated for bacteriuria that existed 48 hours after removal of indwelling urethral catheters.[47]

Urologic Interventions

Urologic Intervention
Regimen
▸ TMP-SMX DS 1 tab bid x 3 days


Due to high risk of bacteremia (60%) and sepsis(6-10%) because of traumatic genitourinary procedures,[48] and the effectiveness of antimicrobials to prevent these complications;[49] [48] [50] screening for bacteriuria and antimicrobial therapy is recommended before the initiation of invasive urologic procedures like transurethral resection of prostate.[49][50]

  • Antibiotic therapy usually discontinued after the procedure, unless there is an indwelling urethral catheter until removed. [48][49]

Immunocompromised Patients and Other Patients

Poor transplant prognosis and complications hasn't been associated with asymptomatic bacteriuria,[51][52]so there is no benefit from screening[53][54] for or treatment of asymptomatic bacteriuria in renal transplant or other solid organ[55] transplant patients.[11]

References

  1. ↑ http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001548/
  2. ↑ Rubin, RH.; Shapiro, ED.; Andriole, VT.; Davis, RJ.; Stamm, WE. (1992). "Evaluation of new anti-infective drugs for the treatment of urinary tract infection. Infectious Diseases Society of America and the Food and Drug Administration". Clin Infect Dis. 15 Suppl 1: S216–27. PMID 1477233. Unknown parameter |month= ignored (help)
  3. ↑ KASS, EH. (1956). "Asymptomatic infections of the urinary tract". Trans Assoc Am Physicians. 69: 56–64. PMID 13380946.
  4. ↑ KASS, EH. (1957). "Bacteriuria and the diagnosis of infections of the urinary tract; with observations on the use of methionine as a urinary antiseptic". AMA Arch Intern Med. 100 (5): 709–14. PMID 13468815. Unknown parameter |month= ignored (help)
  5. ↑ 5.0 5.1 Nicolle, LE. (2003). "Asymptomatic bacteriuria: when to screen and when to treat". Infect Dis Clin North Am. 17 (2): 367–94. PMID 12848475. Unknown parameter |month= ignored (help)
  6. ↑ Zhanel, GG.; Harding, GK.; Nicolle, LE. "Asymptomatic bacteriuria in patients with diabetes mellitus". Rev Infect Dis. 13 (1): 150–4. PMID 2017615.
  7. ↑ 7.0 7.1 Nicolle, LE. (1997). "Asymptomatic bacteriuria in the elderly". Infect Dis Clin North Am. 11 (3): 647–62. PMID 9378928. Unknown parameter |month= ignored (help)
  8. ↑ 8.0 8.1 Waites, KB.; Canupp, KC.; DeVivo, MJ. (1993). "Epidemiology and risk factors for urinary tract infection following spinal cord injury". Arch Phys Med Rehabil. 74 (7): 691–5. PMID 8328888. Unknown parameter |month= ignored (help)
  9. ↑ Bakke, A.; Digranes, A. (1991). "Bacteriuria in patients treated with clean intermittent catheterization". Scand J Infect Dis. 23 (5): 577–82. PMID 1767253.
  10. ↑ Chaudhry, A.; Stone, WJ.; Breyer, JA. (1993). "Occurrence of pyuria and bacteriuria in asymptomatic hemodialysis patients". Am J Kidney Dis. 21 (2): 180–3. PMID 8430679. Unknown parameter |month= ignored (help)
  11. ↑ 11.0 11.1 11.2 Nicolle LE, Bradley S, Colgan R, Rice JC, Schaeffer A, Hooton TM; et al. (2005). "Infectious Diseases Society of America guidelines for the diagnosis and treatment of asymptomatic bacteriuria in adults". Clin Infect Dis. 40 (5): 643–54. doi:10.1086/427507. PMID 15714408.
  12. ↑ Stamm, WE. (1983). "Measurement of pyuria and its relation to bacteriuria". Am J Med. 75 (1B): 53–8. PMID 6349345. Unknown parameter |month= ignored (help)
  13. ↑ Hooton, TM.; Scholes, D.; Stapleton, AE.; Roberts, PL.; Winter, C.; Gupta, K.; Samadpour, M.; Stamm, WE. (2000). "A prospective study of asymptomatic bacteriuria in sexually active young women". N Engl J Med. 343 (14): 992–7. doi:10.1056/NEJM200010053431402. PMID 11018165. Unknown parameter |month= ignored (help)
  14. ↑ Zhanel, GG.; Nicolle, LE.; Harding, GK. (1995). "Prevalence of asymptomatic bacteriuria and associated host factors in women with diabetes mellitus. The Manitoba Diabetic Urinary Infection Study Group". Clin Infect Dis. 21 (2): 316–22. PMID 8562738. Unknown parameter |month= ignored (help)
  15. ↑ Bachman, JW.; Heise, RH.; Naessens, JM.; Timmerman, MG. (1993). "A study of various tests to detect asymptomatic urinary tract infections in an obstetric population". JAMA. 270 (16): 1971–4. PMID 8411555. Unknown parameter |month= ignored (help)
  16. ↑ KINCAID-SMITH, P.; BULLEN, M. (1965). "BACTERIURIA IN PREGNANCY". Lancet. 1 (7382): 395–9. PMID 14238090. Unknown parameter |month= ignored (help)
  17. ↑ Nicolle, LE.; Duckworth, H.; Brunka, J.; Urias, B.; Kennedy, J.; Murray, D.; Harding, GK. (1998). "Urinary antibody level and survival in bacteriuric institutionalized older subjects". J Am Geriatr Soc. 46 (8): 947–53. PMID 9706881. Unknown parameter |month= ignored (help)
  18. ↑ 18.0 18.1 Harding, GK.; Zhanel, GG.; Nicolle, LE.; Cheang, M. (2002). "Antimicrobial treatment in diabetic women with asymptomatic bacteriuria". N Engl J Med. 347 (20): 1576–83. doi:10.1056/NEJMoa021042. PMID 12432044. Unknown parameter |month= ignored (help)
  19. ↑ Darouiche, RO.; Cadle, RM.; Zenon, GJ.; Markowski, J.; Rodriguez, M.; Musher, DM. (1993). "Progression from asymptomatic to symptomatic urinary tract infection in patients with SCI: a preliminary study". J Am Paraplegia Soc. 16 (4): 219–24. PMID 8270918. Unknown parameter |month= ignored (help)
  20. ↑ Rubin RH, Shapiro ED, Andriole VT, Davis RJ, Stamm WE (1992). "Evaluation of new anti-infective drugs for the treatment of urinary tract infection. Infectious Diseases Society of America and the Food and Drug Administration". Clin Infect Dis. 15 Suppl 1: S216–27. PMID 1477233.
  21. ↑ Evans DA, Williams DN, Laughlin LW, Miao L, Warren JW, Hennekens CH; et al. (1978). "Bacteriuria in a population-based cohort of women". J Infect Dis. 138 (6): 768–73. PMID 368263‎ Check |pmid= value (help).
  22. ↑ Kunin CM, McCormack RC (1968). "An epidemiologic study of bacteriuria and blood pressure among nuns and working women". N Engl J Med. 278 (12): 635–42. doi:10.1056/NEJM196803212781201. PMID 4866351.
  23. ↑ 23.0 23.1 Bengtsson C, Bengtsson U, Björkelund C, Lincoln K, Sigurdsson JA (1998). "Bacteriuria in a population sample of women: 24-year follow-up study. Results from the prospective population-based study of women in Gothenburg, Sweden". Scand J Urol Nephrol. 32 (4): 284–9. PMID 9764457.
  24. ↑ 24.0 24.1 Nicolle LE (1997). "Asymptomatic bacteriuria in the elderly". Infect Dis Clin North Am. 11 (3): 647–62. PMID 9378928.
  25. ↑ Warren JW, Tenney JH, Hoopes JM, Muncie HL, Anthony WC (1982). "A prospective microbiologic study of bacteriuria in patients with chronic indwelling urethral catheters". J Infect Dis. 146 (6): 719–23. PMID 6815281.
  26. ↑ Lipsky BA, Inui TS, Plorde JJ, Berger RE (1984). "Is the clean-catch midstream void procedure necessary for obtaining urine culture specimens from men?". Am J Med. 76 (2): 257–62. PMID 6695949.
  27. ↑ Mims AD, Norman DC, Yamamura RH, Yoshikawa TT (1990). "Clinically inapparent (asymptomatic) bacteriuria in ambulatory elderly men: epidemiological, clinical, and microbiological findings". J Am Geriatr Soc. 38 (11): 1209–14. PMID 2246458.
  28. ↑ Tencer J (1988). "Asymptomatic bacteriuria--a long-term study". Scand J Urol Nephrol. 22 (1): 31–4. PMID 3387908.
  29. ↑ Asscher AW, Sussman M, Waters WE, Evans JA, Campbell H, Evans KT; et al. (1969). "Asymptomatic significant bacteriuria in the non-pregnant woman. II. Response to treatment and follow-up". Br Med J. 1 (5647): 804–6. PMC 1982498. PMID 4886627.
  30. ↑ "Screening for asymptomatic bacteriuria, hematuria and proteinuria. The U.S. Preventive Services Task Force". Am Fam Physician. 42 (2): 389–95. 1990. PMID 2200247. Unknown parameter |month= ignored (help)
  31. ↑ Stenqvist, K.; Dahlén-Nilsson, I.; Lidin-Janson, G.; Lincoln, K.; Odén, A.; Rignell, S.; Svanborg-Edén, C. (1989). "Bacteriuria in pregnancy. Frequency and risk of acquisition". Am J Epidemiol. 129 (2): 372–9. PMID 2912046. Unknown parameter |month= ignored (help)
  32. ↑ Wadland, WC.; Plante, DA. (1989). "Screening for asymptomatic bacteriuria in pregnancy. A decision and cost analysis". J Fam Pract. 29 (4): 372–6. PMID 2794885. Unknown parameter |month= ignored (help)
  33. ↑ Smaill F (2001). "Antibiotics for asymptomatic bacteriuria in pregnancy". Cochrane Database Syst Rev (2): CD000490. doi:10.1002/14651858.CD000490. PMID 11405965‎ Check |pmid= value (help).
  34. ↑ Mittendorf R, Williams MA, Kass EH (1992). "Prevention of preterm delivery and low birth weight associated with asymptomatic bacteriuria". Clin Infect Dis. 14 (4): 927–32. PMID 1533541.
  35. ↑ Romero R, Oyarzun E, Mazor M, Sirtori M, Hobbins JC, Bracken M (1989). "Meta-analysis of the relationship between asymptomatic bacteriuria and preterm delivery/low birth weight". Obstet Gynecol. 73 (4): 576–82. PMID 2927852.
  36. ↑ Geerlings, SE.; Stolk, RP.; Camps, MJ.; Netten, PM.; Collet, JT.; Schneeberger, PM.; Hoepelman, AI. (2001). "Consequences of asymptomatic bacteriuria in women with diabetes mellitus". Arch Intern Med. 161 (11): 1421–7. PMID 11386891. Unknown parameter |month= ignored (help)
  37. ↑ Semetkowska-Jurkiewicz, E.; Horoszek-Maziarz, S.; Galiński, J.; Manitius, A.; Krupa-Wojciechowska, B. "The clinical course of untreated asymptomatic bacteriuria in diabetic patients--14-year follow-up". Mater Med Pol. 27 (3): 91–5. PMID 8935144.
  38. ↑ Boscia, JA.; Kobasa, WD.; Knight, RA.; Abrutyn, E.; Levison, ME.; Kaye, D. (1987). "Therapy vs no therapy for bacteriuria in elderly ambulatory nonhospitalized women". JAMA. 257 (8): 1067–71. PMID 3806896. Unknown parameter |month= ignored (help)
  39. ↑ Nordenstam, GR.; Brandberg, CA.; Odén, AS.; Svanborg Edén, CM.; Svanborg, A. (1986). "Bacteriuria and mortality in an elderly population". N Engl J Med. 314 (18): 1152–6. doi:10.1056/NEJM198605013141804. PMID 3960089. Unknown parameter |month= ignored (help)
  40. ↑ Heinämäki, P.; Haavisto, M.; Hakulinen, T.; Mattila, K.; Rajala, S. (1986). "Mortality in relation to urinary characteristics in the very aged". Gerontology. 32 (3): 167–71. PMID 3721209.
  41. ↑ 41.0 41.1 Nicolle, LE.; Mayhew, WJ.; Bryan, L. (1987). "Prospective randomized comparison of therapy and no therapy for asymptomatic bacteriuria in institutionalized elderly women". Am J Med. 83 (1): 27–33. PMID 3300325. Unknown parameter |month= ignored (help)
  42. ↑ Abrutyn, E.; Mossey, J.; Berlin, JA.; Boscia, J.; Levison, M.; Pitsakis, P.; Kaye, D. (1994). "Does asymptomatic bacteriuria predict mortality and does antimicrobial treatment reduce mortality in elderly ambulatory women?". Ann Intern Med. 120 (10): 827–33. PMID 7818631. Unknown parameter |month= ignored (help)
  43. ↑ Erickson, RP.; Merritt, JL.; Opitz, JL.; Ilstrup, DM. (1982). "Bacteriuria during follow-up in patients with spinal cord injury: I. Rates of bacteriuria in various bladder-emptying methods". Arch Phys Med Rehabil. 63 (9): 409–12. PMID 7115037. Unknown parameter |month= ignored (help)
  44. ↑ Sobel, JD.; Kauffman, CA.; McKinsey, D.; Zervos, M.; Vazquez, JA.; Karchmer, AW.; Lee, J.; Thomas, C.; Panzer, H. (2000). "Candiduria: a randomized, double-blind study of treatment with fluconazole and placebo. The National Institute of Allergy and Infectious Diseases (NIAID) Mycoses Study Group". Clin Infect Dis. 30 (1): 19–24. doi:10.1086/313580. PMID 10619727. Unknown parameter |month= ignored (help)
  45. ↑ Warren, JW.; Anthony, WC.; Hoopes, JM.; Muncie, HL. (1982). "Cephalexin for susceptible bacteriuria in afebrile, long-term catheterized patients". JAMA. 248 (4): 454–8. PMID 7045440. Unknown parameter |month= ignored (help)
  46. ↑ Alling, B.; Brandberg, A.; Seeberg, S.; Svanborg, A. (1975). "Effect of consecutive antibacterial therapy on bacteriuria in hospitalized geriatric patients". Scand J Infect Dis. 7 (3): 201–7. PMID 809837.
  47. ↑ Harding, GK.; Nicolle, LE.; Ronald, AR.; Preiksaitis, JK.; Forward, KR.; Low, DE.; Cheang, M. (1991). "How long should catheter-acquired urinary tract infection in women be treated? A randomized controlled study". Ann Intern Med. 114 (9): 713–9. PMID 2012351. Unknown parameter |month= ignored (help)
  48. ↑ 48.0 48.1 48.2 Grabe, M. (1987). "Antimicrobial agents in transurethral prostatic resection". J Urol. 138 (2): 245–52. PMID 3298693. Unknown parameter |month= ignored (help)
  49. ↑ 49.0 49.1 49.2 Cafferkey, MT.; Falkiner, FR.; Gillespie, WA.; Murphy, DM. (1982). "Antibiotics for the prevention of septicaemia in urology". J Antimicrob Chemother. 9 (6): 471–7. PMID 7107549. Unknown parameter |month= ignored (help)
  50. ↑ 50.0 50.1 Allan, WR.; Kumar, A. (1985). "Prophylactic mezlocillin for transurethral prostatectomy". Br J Urol. 57 (1): 46–9. PMID 3971104. Unknown parameter |month= ignored (help)
  51. ↑ Takai, K.; Tollemar, J.; Wilczek, HE.; Groth, CG. (1998). "Urinary tract infections following renal transplantation". Clin Transplant. 12 (1): 19–23. PMID 9541418. Unknown parameter |month= ignored (help)
  52. ↑ Lyerová, L.; Lácha, J.; Skibová, J.; Teplan, V.; Vítko, S.; Schück, O. (2001). "Urinary tract infection in patients with urological complications after renal transplantation with respect to long-term function and allograft survival". Ann Transplant. 6 (2): 19–20. PMID 11803612.
  53. ↑ Ghasemian, SM.; Guleria, AS.; Khawand, NY.; Light, JA. (1996). "Diagnosis and management of the urologic complications of renal transplantation". Clin Transplant. 10 (2): 218–23. PMID 8664523. Unknown parameter |month= ignored (help)
  54. ↑ Kasiske, BL.; Vazquez, MA.; Harmon, WE.; Brown, RS.; Danovitch, GM.; Gaston, RS.; Roth, D.; Scandling, JD.; Singer, GG. (2000). "Recommendations for the outpatient surveillance of renal transplant recipients. American Society of Transplantation". J Am Soc Nephrol. 11 Suppl 15: S1–86. PMID 11044969. Unknown parameter |month= ignored (help)
  55. ↑ "Guidelines for preventing opportunistic infections among hematopoietic stem cell transplant recipients". MMWR Recomm Rep. 49 (RR-10): 1–125, CE1–7. 2000. PMID 11718124. Unknown parameter |month= ignored (help)
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