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Geriatr Gerontol Int 2017; 17: 1076–1080

O R I G I N A L A R T I C L E : E P I D E M I O L O G Y,
C L I N I C A L P R A C T I C E A N D H E A LT H

Prevalence and prognostic influence of bacterial pyuria in

elderly patients with pneumonia: A retrospective study
Hiroaki Oka,1,2,5 Kosaku Komiya,1,2,5 Minoru Ohama,1,5 Yoshiyuki Kawano,1 Masahiro Uchida,1
Hajime Miyajima,1 Tomohiko Iwashita,1 Eiji Okabe,1 Tadao Kawamura,3 Kazuhiro Yasuda,4
Taisuke Matsumoto1 and Jun-ichi Kadota5
1
Department of Internal Medicine, 2Clinical Research Center of Respiratory Medicine, 3Neurosurgery, 4Gastroenterological Surgery, Tenshindo
Hetsugi Hospital and 5Respiratory Medicine, and Infectious Diseases, Oita University Faculty of Medicine, Oita, Japan

Aim: The number of elderly patients with pneumonia is significantly increasing as the populations in many countries
age. Although elderly patients with pneumonia are at risk of developing urinary tract infections, no studies have examined
the prevalence or the prognostic impact of this complication. The aim of the present study was to investigate the preva-
lence of comorbid bacterial pyuria and the impact on the prognosis of elderly patients with pneumonia.
Methods: We retrospectively evaluated 132 patients aged >65 years who were hospitalized for pneumonia and who
underwent a urinary sediment test on admission. The background characteristics, laboratory results and treatment regi-
mens were documented, and the risk factors for the complication of bacterial pyuria and its association with 90-day mor-
tality in pneumonia patients were elucidated.
Results: A total of 37 (28%) of 132 patients were complicated by bacterial pyuria. The patients with bacterial pyuria were
more often women, showed a poorer performance status, were more frequently fed by percutaneous endoscopic
gastrostomy, and more frequently used diapers and/or a bladder catheter. Regarding first-line drugs, 82.6% of the patients
received beta-lactamase inhibitors and extended-spectrum penicillins. The use of a bladder catheter and a poor perfor-
mance status were associated with bacterial pyuria. A multivariate analysis showed that a poor performance status was
the only factor associated with 90-day mortality.
Conclusions: Bacterial pyuria did not affect the prognosis of patients who were treated with penicillin-based regimens.
Thus, broad-spectrum antibiotics are not necessarily required for elderly patients with pneumonia complicated by urinary
tract infection. Geriatr Gerontol Int 2017; 17: 1076–1080.

Keywords: bacterial pyuria, bacteriuria, elderly patient, pneumonia, urinary tract infection.

Introduction high as 7.5–30%.2 UTI can therefore be life-threatening

The incidence of pneumonia is increasing as the popula-
tion ages. The decreased immune function of older adults
allows them to be complicated with other infections.
Urinary tract infections (UTI) are the second most com-
mon form of infectious disease (after pneumonia) in the
elderly population.1 Although the overall mortality rate
of pyelonephritis, a typical UTI, is approximately 0.3%,
elderly patients with pyelonephritis are susceptible to bac-
teremia, the mortality rate of which is reported to be as
if physicians do not diagnose them promptly and provide
appropriate treatment to elderly patients with pneumonia.
However, there have been no studies regarding the clinical
impact of UTI as a complication in pneumonia patients.
The present study aimed to investigate the prevalence of
bacterial pyuria and its relationship with the prognosis of
pneumonia in elderly patients.
Methods

Study design and participants

Accepted for publication 13 April 2016.
Correspondence: Dr Hiroaki Oka MD PhD, Department of Internal
Medicine and Clinical Research Center of Respiratory Medicine,
Tenshindo Hetsugi Hospital, 5956 Nakahetsugi, Oita 879–7761, Japan.
Email: ch9a4g63@oita-u.ac.jp
This was a retrospective observational study that was car-
ried out in a single facility. The study population included
patients who were aged >65 years who required hospital-
ization for pneumonia, and who underwent a urinary test
between January 2012 and April 2014 at Tenshindo

1076 | doi: 10.1111/ggi.12830 © 2016 Japan Geriatrics Society

 Influence of bacterial pyuria
Hetsugi Hospital, Japan, an acute care hospital with 173
beds, in Oita, Japan. Patients who were aged <65 years,
or who had interstitial pneumonia, pneumomycosis, ma-
lignant tumors or other coexisting diseases, which could
be obvious sources of fever (other than respiratory tract
or urinary tract infections), were excluded from the pres-
ent study. The primary outcome was 90-day mortality
after hospitalization for pneumonia; the secondary out-
come was the risk factors for the complication of pyuria
in patients with pneumonia. The study protocol was
approved by the ethics committee of the hospital (approval
number 13010; approval date 23 July 2014).
Definitions
Pneumonia was defined by radiological evidence with
fever or hypothermia at the time of examination (tempera-
ture >38 °C or <35 °C, or cases in which fever or hypo-
thermia could be confirmed to have occurred within 48 h
before hospitalization through the records of the intro-
ducing hospital or previous physician), in addition to the
confirmation of two or more of the following symptoms:
coughing, dyspnea, respiratory failure and purulent spu-
tum.3 Pyuria was defined as a leukocyte count of ≧ 10/
mm3 in a urine specimen that had not been centrifuged,
or a leukocyte count of ≧ 5/high power field in a urine spec-
imen that had been centrifuged. Bacteriuria was defined
by the observation of one or more bacteria in each field
of a high-power field.4,5 Broad-spectrum antibiotics were
defined by the characteristics of their antipseudomonal
and/or anti-methicillin-resistant Staphylococcus aureus
activity.
Statistical analysis
The PASW statistics 22.0 software package (IBM SPSS,
Tokyo, Japan) was used for the statistical analyses in
the present study. For “bacteria pyuria compound” and
“rate of death after 90 days” the α value was set at
0.05, and the β value was set at 0.2. With an effect size
of 0.3 (χ 2-test), the required target sample size was 88
patients. The patients who met the inclusion criteria
were separated into a bacterial pyuria compound group
and a non-compound group. We compared the back-
ground factors, carried out a blood analysis and investi-
gated the imaging findings. Student’s t-test and the
Mann–Whitney U-test were carried out for interval
scales, while the χ 2-test or Fisher’s exact test were car-
ried out for nominal and ordinal scales. The confidence
interval of the two-sided analyses was set at 95%. Mul-
tivariate analyses were carried out with selected items,
mainly those in which a significant difference was
observed between the two groups using the forced entry
method. These stratified parameters were used to draft a
Kaplan–Meier curve and carry out a log–rank test to
compare the rate of 90-day mortality in the bacterial
pyuria compound and non-compound groups. The
© 2016 Japan Geriatrics Society
Cox proportional hazards model was used to analyze
the factors in the cases that were complicated by bacte-
rial pyuria after adjusting for other variables.
Results
Patient characteristics
During the observation period, 316 patients were admit-
ted for pneumonia, 132 of the patients met the inclusion
criteria. A total of 37 cases were complicated by bacterial
pyuria; 95 were not. Although there was no significant
difference in age, the bacterial pyuria complicated group
included a significantly higher proportion of women and
patients with a longer hospital stay (Table 1). No statistical
differences were observed in the C-reactive protein and
albumin levels, whereas the sequential organ failure
assessment score was higher in the cases that were compli-
cated with bacterial pyuria. The use of bladder catheters,
percutaneous endoscopic gastrostomy or diapers, a diag-
nosis of nursing and healthcare-associated pneumonia
(as defined by the Japanese Respiratory Society) or a poor
performance status (PS) were associated with a higher
prevalence of bacterial pyuria. There were no significant
differences in the selection of antibiotics in the bacterial
pyuria compound and non-compound groups (Table 2).
A majority of the patients (62.9 %) were treated with
ampicillin/sulbactam alone or as combined therapy at the
time of admission, followed by piperacillin/tazobactam
alone or as combined therapy in 19.7% of the cases.
Bacteriological findings
Microbiological examinations of the sputum were car-
ried out in 56% of 316 patients with pneumonia. The
leading six causative organisms were as follows: Klebsi-
ella pneumoniae (9.1%), Pseudomonas aeruginosa (9.1%),
methicillin-sensitive Streptococcus aureus (9.1%),
methicillin-resistant Streptococcus aureus (9.1%) Hae-
mophilus influenzae (8.5%) and Streptococcus pneumoniae
(7.9%). Just 2% of the admitted patients underwent bi-
ological examinations of urine, which showed no
specific tendency. The leading six UTI causative
organisms isolated from 401 urine specimens in our
hospital during the surveillance period were as follows:
Enterococcus faecalis (22.9%), Escherichia coli (10.5%),
Pseudomonas aeruginosa (10.5%), methicillin-resistant
Streptococcus aureus (8.5%), Klebsiella pneumoniae (3.0%)
and methicillin-sensitive Staphylococcus aureus (2.0%).
Ninety-day mortality in the patients with pneumonia
with or without bacterial pyuria and the risk factors for
bacterial pyuria
The survival curve showed that the coexistence of
bacterial pyuria had no significant effect on survival
(Figure 1). A multivariate logistic regression analysis
| 1077
 H Oka et al.

Table 1 Baseline characteristics of the pneumonia patients

Bacterial pyuria (n = 37) Non-bacterial pyuria (n = 95) P

Female 22 (60) 37 (39) 0.033
Age (years) 88.0 (81.5–95.0) 86.0 (80.5–91.5) 0.438
Hospital stay (days) 28.0 (3.5–52.5) 21.0 (3.0–39.0) 0.037
Body temperature (°C) 37.5 (37.0–38.0) 37.6 (37.1–38.1) 0.473
PaO2/FiO2 ≦ 300 17(46) 32(34) 0.190
Systolic blood pressure (mmHg) 119 (108–140) 128 (115–141) 0.057
Diastolic blood pressure (mmHg) 66 (54–79) 70 (62–78) 0.068
Heart rate (b.p.m.) 90 (77–103) 88 (75–102) 0.412
WBC (/μL) 9030 (6625–11 435) 10 070 (7020–13 120) 0.477
Hb (g/dL) 11.2 (10.1–12.3) 11.8 (10.2–13.4) 0.370
Plt (×105/μL) 15.8 (11.4–20.2) 19.7(14.7–24.8) 0.004
BUN (mg/dL) 19.2(12.1–26.3) 21.5 (15.8–27.3) 0.984
Creatinine (mg/dL) 0.89 (0.54–1.25) 0.93 (0.61–1.25) 0.887
Albumin (g/dL) 3.20 (2.85–3.55) 3.30 (2.85–3.75) 0.475
C-reactive protein (mg/dL) 9.09 (3.45–14.74) 8.73 (5.27–14.00) 0.757
SOFA score 3 (1.5–4.5) 2 (1–3) 0.008
Body mass index (kg/m2) 18.6 (16.5–20.8) 19.94 (17.1–22.8) 0.180
Bladder catheter 7 (19) 2 (2) 0.001
Percutaneous endoscopic gastrostomy 8 (22) 7 (7.4) 0.020
Continuous use of diapers 17 (46) 22 (23) 0.010
NHCAP 32 (87) 62 (65) 0.016
Dementia 21 (57) 39 (41) 0.104
Performance status 3 (2.5–3.5) 2 (1–3) 0.000
Success rate of first-line antibiotics (%) 34 (92) 84 (88) 0.561
Broad-spectrum antibiotics (%) 15 (41) 31 (33) 0.392
Diabetes mellitus 3 (8) 14 (15) 0.298
Chronic heart failure 18 (46) 60 (65) 0.047
Data expressed as number (%) or median (interquartile range). BUN, blood urea nitrogen; Hb, hemoglobin; LAMA, long-acting mus-
carinic antagonists; NHCAP, nursing and healthcare associated pneumonia; PEG, percutaneous endoscopic gastrostomy; Plt, platelet;
SOFA, sequential organ failure assessment; WBC, white blood cell.

showed that bladder catheter use and a poor PS were as-
sociated with bacterial pyuria (Table 3). A Cox hazards
analysis showed that a poor PS was the only factor that
was significantly associated with 90-day mortality. The
complication of bacterial pyuria did not affect the
mortality rate of the patients in the present study (
Table 4).
Discussion
The present study showed that the prevalence of bacterial
pyuria (approximately 30%) was not so high in elderly pa-
tients with pneumonia (Table 1). This was lower than the
rate of asymptomatic pyuria in long-term care facilities
(approximately 90%).6,7 This discrepancy might be ex-
plained by the fact that although our study population
was composed of elderly patients, they did not all come
from long-term facilities.
Second, although the risk factors for bacterial pyuria
in patients with pneumonia (bladder catheter use and
poor PS) were consistent with the commonly accepted
evidence on the risk factors for UTI, our data showed
that the complication of bacterial pyuria in elderly pa-
tients with pneumonia was not significantly associated
with 90-day mortality when the patients were treated
with a penicillin-based antibiotic regimen, such as
ampicillin/sulbactam or piperacillin/tazobactam (Table 3
, Fig. 1). Similarly, no significant relationship was
observed with 30-day and in-hospital mortality (data
not shown). This might be because these drug combina-
tions result in better therapeutic effects, not only in pa-
tients with pneumonia, but also in patients with
comorbid UTI, as the two drugs have a sensitivity rate
of ≥80% against the causative agents of the UTI that
were typically detected in the urine cultures of patients
at our hospital from 2012 to 2014 (data not shown). In
line with our previous finding regarding the treatment
of elderly patients with pneumonia in which the pa-
tients’ prognoses mainly depended on host factors, such
as the overall body condition and nutritional condition,

1078 | © 2016 Japan Geriatrics Society

 Influence of bacterial pyuria

Table 2 Characteristics of the selected antibiotics in the rather than the type of antibacterial drug, a poor PS was
pneumonia patients associated with 90-day mortality in the present study.8 It
is therefore more important to properly prevent illness
Bacterial pyuria Bacterial pyuria and the deterioration of the PS of elderly patients.
compound non-compound To our knowledge, this is the first study to show the
(n = 37) (n = 95) prevalence of comorbid bacterial pyuria and its impact
ABPC/SBT 18 (49) 53 (56) on the prognosis of elderly patients with pneumonia.
ABPC/SBT 3(8) 4 (4) However, the present study is associated with several
+ new quinolone limitations. First, it was a retrospective study based on
ABPC/SBT 0 (0) 4 (4) medical records. The patients who were admitted with
+ macrolide pneumonia did not always undergo a urinary sediment
ABPC/SBT + TEIC 0 (0) 1 (1) test. Thus, the possibility of bias arising from the
PIPC/TAZ 6 (16) 12 (13) clinical findings and physicians’ judgment cannot be
PIPC/TAZ + 1 (3) 1 (1) eliminated. Second, a thorough bacteriological investi-
new quinolone gation could not be carried out. Accordingly, it was dif-
PIPC/TAZ 1 (3) 5 (5) ficult to evaluate the effectiveness of the antibiotics that
+ macrolide were given to the recruited patients. Third, the condi-
PIPC 2 (5) 2 (2) tion of the patients who were diagnosed with bacterial
AZM 1 (3) 0 (0) pyuria based on urinary sediment findings was not
LVFX 0 (0) 4 (4) necessarily identical to the condition of the patients
LVFX + CPZ/SBT 0 (0) 1 (1) who are treated for UTI, as in many cases patients
CTRX 3 (8) 6 (6) without clinical symptoms do not require medical care,
CPZ/SBT 0 (0) 1 (1) even if bacteriuria is detected.9 Woodforth et al.
DRPM 1 (3) 0 (0) reported that in a study population of patients aged
MEPM 1 (3) 1 (1) >75 years, 48.7% of the patients who were diagnosed
with a UTI showed traditional UTI-related symptoms,
Data expressed as number (%). ABPC/SBT, ampicillin/sulbactam;
AZM, azithromycin; CPZ/SBT, cefoperazone/sulbactam; CTRX,
whereas such symptoms were present in 10.4% of the
ceftriaxone; DRPM, doripenem; LVFX, levofloxacin; MEPM, patients who were deemed to not have a UTI.10 This
meropenem; PIPC, piperacillin; TAZ, tazobactam; TEIC, teicoplanin. shows that the existence of typical symptoms alone is
not enough to either diagnose or dismiss a UTI. Fur-
thermore, the McGeer diagnostic standards referenced
by the Society for Healthcare Epidemiology of America
and Centers for Disease Control and Prevention
exclude other fever-producing illnesses and/or subjec-
tive symptoms from the diagnostic standards for
UTI.11 It therefore appears to be difficult for physicians
to differentiate cases of pneumonia in elderly patients
complicated by asymptomatic bacteriuria from those
complicated by UTI. In the clinical setting, the
treatment of elderly patients often requires prompt
treatment decisions. Physicians should therefore at
least be aware that UTI that show pyuria and bacteri-
uria might occur in patients with pneumonia. In this
context, even if UTI were overdiagnosed in the present
study, our results showed that the penicillin-based
regimens should be effective in the cases that were
complicated by UTI.
In conclusion, although a large prospective study is
required to microbiologically evaluate the effectiveness
of antibiotics against coinfection with bacterial pyuria
in pneumonia patients, penicillin-based antibiotic regi-
mens seem to be effective in patients with pneumonia
Figure 1 A Kaplan–Meier analysis of the survival of pneumonia complicated by UTI. The results of the present study
patients with and without bacterial pyuria. The survival of patients
with pneumonia complicated by bacterial pyuria did not differ suggest that such patients might be more effectively
from that of pneumonia patients without bacterial pyuria (log– managed by exchanging ideas with other fields, such as
rank test, P = 0.654). urology.

© 2016 Japan Geriatrics Society | 1079

 H Oka et al.

Table 3 Risk factors for urinary tract infection

Crude OR P Adjusted OR† P

Female 2.299 (1.059–4.991) 0.035 2.096 (0.863–5.5090) 0.102.
Bladder catheter 10.850 (2.138–55.071) 0.004 6.703 (1.228–36.576) 0.028
Performance status 1.863 (1.314–2.641) 0.000 1.712 (1.109–2.644) 0.015
Dementia 1.885 (0.874–4.063) 0.106 0.656 (0.238–1.806) 0.414
SOFA score 1.377 (1.078–1.744) 0.008 1.278 (0.983–1.661) 0.067
Data expressed as the hazard ratio (95% confidence interval). †Adjusted for variables using the forced entry method. SOFA, sequential
organ failure assessment.

Table 4 Cox proportional hazards model for the factors associated with a risk of 90-day mortality

Crude HR P Adjusted HR† P

Female 0.915 (0.317–2.636) 0.869 0.634 (0.203–1.974) P = 0.431
Bladder catheter 0.948 (0.124–7.249) 0.959 0.549 (0.064–4.698) P = 0.584
Performance status 1.878 (1.124–3.138) 0.016 1.945 (1.063–3.559) P = 0.031
Dementia 2.317 (0.777–6.915) 0.132 0.906 (0.245–3.352) P = 0.883
Bacterial pyuria 1.345 (0.451–4.013) 0.595 1.073 (0.318–3.622) P = 0.910
Broad-spectrum antibiotics 0.935 (0.313–2.791) 0.904 0.977 (0.292–3.269) P = 0.970
SOFA score 1.198 (0.928–1.547) 0.165 1.095 (0.826–1.452) P = 0.529
Data expressed as the hazard ratio (95% confidence interval). †Adjusted for variables using the forced entry method. SOFA, sequential
organ failure assessment.

Acknowledgments care-associated, and hospital-acquired pneumonia. Ann Intern

We greatly thank Mr Eto (medical technologist, Tenshindo
Hetsugi Hospital), and Ms Okubayashi, Ms Torii, Ms
Egoshi and Ms Kudoh (health information manager,
Tenshindo Hetsugi Hospital) for valuable assistance with
collecting the data.
Disclosure statement
The authors declare no conflict of interest.
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1080 | © 2016 Japan Geriatrics Society