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Urinary tract infections and purple urine bag syndrome- A neglected entity
*Corresponding author: Jyoti Jindal, Department of Medicine, Dayanand Medical College and Hospital, Ludhiana, Punjab, India. jyoti_jindal2000@yahoo.co.in
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Received: ,
Accepted: ,
How to cite this article: Jindal J, Garg V, Gupta V. Urinary tract infections and purple urine bag syndrome- A neglected entity. J Lab Physicians. doi: 10.25259/JLP_128_2024
Abstract
Purple Urine Bag Syndrome (PUBS) is a rare condition characterized by the discoloration of urine bags in patients with prolonged catheterization. Objectives of the study is to report a case series of PUBS and highlight its association with underlying urinary tract infections (UTIs). This is a prospective observational case series included 15 adult patients with PUBS and prolonged catheterization between June 2023 and March 2024. Results of Our case series included 10 male and 5 female patients, with a mean age of 72 years. The majority had comorbidities like chronic kidney disease (53.3%), type 2 diabetes mellitus (46.7%), and hypertension (40%). All patients had undergone prolonged catheterization, with a mean duration of 6 weeks. Urine culture showed growth of Klebsiella, E. coli, and Pseudomonas aeruginosa. In conclusion PUBS is a rare but significant condition that requires prompt attention to prevent complications. Healthcare professionals should be aware of this entity and take necessary measures to prevent and manage UTIs in patients with prolonged catheterization.
Keywords
Purple urine bag syndrome
Urinary tract infections
Prolonged catheterization
Healthcare-associated infections
INTRODUCTION
Purple urine bag syndrome (PUBS) is a very rare entity presenting as a purple discoloration of urine. It occurs due to urinary tract infection by bacteria that metabolize tryptophan into indigo, and indirubin pigments precipitate inside the urine bag system, giving it a purple hue, and is mostly seen in patients who are bedridden and catheterized for a long time.[1] Patients with purple urine usually do not complain of any symptoms. The purple discoloration of the urine bag is often the only finding frequently noted by caregivers. Despite being a benign condition, PUBS is alarming as it is often associated with urinary tract infections (UTIs) and their complications. There are various factors that increase the risk including poverty, using a polyvinyl catheter, and having an underlying health condition.[2,3] It was first described in 1978 by Barlow and Dickson, and since then, it has been observed repeatedly in bedridden elderly patients.[3,4] There are very few studies on PUBS done in india.The studies done by Ahmed et al and Ansari et al include only one case.There is another larger indian study done by Kumar et al include 46 cases.[5-7] PUBS can help in early identification of patients with UTI and prevent further complications. The aim of our case series was to record the prevalence of predisposing factors in our institute. Therefore, we can draw safe conclusions about its recognition and propose a method for its effective prevention and management. In this study, we have summarized a case series of 15 cases with PUBS.
CASE SERIES
This prospective observational case series was conducted between June 2023 and March 2024. The study was initiated after identifying an index case of PUBS in June 2023, which prompted us to identify additional cases. The index case was a 65-year-old female with type 2 diabetes mellitus, chronic kidney disease, and chronic constipation who developed PUBS after 6 months of catheterization. Following this, we prospectively screened patients with prolonged catheterization and identified 14 additional cases of PUBS and associated UTIs between July 2023 and March 2024. Patient demographics, comorbidities, catheterization duration, and urine culture results were recorded for all 15 cases. The study population consisted of adult patients with PUBS and prolonged catheterization, with a mean age of 72 years. To ensure completeness, we also reviewed catheterization logs and microbiology reports to confirm the diagnosis of PUBS and associated UTIs. All 15 patients were followed up for a median duration of 3 months after PUB’s diagnosis, during which regular urine culture and sensitivity testing were performed, and antibiotic therapy was adjusted as needed. Catheter changes and maintenance were also monitored. The outcome measures assessed in this study were the resolution of PUBS, defined as the disappearance of purple discoloration from the urine bag, and the recurrence of UTIs, defined as the presence of symptoms or a positive urine culture after resolution of PUBS, indicating a new or persistent infection. This prospective observational design allowed us to monitor the development of PUBS in patients with prolonged catheterization and identify potential risk factors.
RESULTS
Our study consisted of 10 males and 5 females, with a mean age of 72 years (range: 60–90 years). The majority had comorbidities, including chronic kidney disease (53.3%), type 2 diabetes mellitus (46.7%), hypertension (40%), chronic constipation (26.7%), cerebrovascular accident (26.7%), coronary artery disease (20%), chronic liver disease (13.3%), and rheumatoid arthritis (6.7%) [Table 1]. The common symptoms included are recurrent UTIs (93.3%), purple-colored urine (100%), and prolonged catheterization (100%). All patients had undergone prolonged catheterization, with a mean duration of 6 weeks (range: 3–8 months). Urine culture showed growth of Klebsiella (40%), Escherichia coli (33.3%), and Pseudomonas aeruginosa (20%), with polymicrobial growth in one patient (6.7%). The cases presented with varied clinical profiles [Table 2]. The cases included a 65-year-old female with type 2 diabetes mellitus, chronic kidney disease, and chronic constipation who developed PUBS after 6 months of illness. An 80-year-old male with chronic kidney disease stage 4 and hypertension developed PUBS after 8 months of catheterization. Other cases included a 70-year-old female with diabetes mellitus, coronary artery disease, and chronic kidney disease stage 3; a 76-year-old male with type 2 diabetes mellitus, diabetic nephropathy, and constipation; and a 75-year-old male with diabetes mellitus, coronary artery disease, UTI, and stricture urethra. A 70-year-old male patient had type 2 diabetes mellitus, diabetic retinopathy, chronic kidney disease stage 2, coronary artery disease with left ventricular systolic dysfunction with ejection fraction - 42%, and left hemiparesis developed PUBs after 5 months of catheterization. Another case of a 72-year-old female patient diagnosed to be having paraparesis (a case of transverse myelitis) and on urine catheter for 4 weeks and developed PUBS. She also had a history of chronic constipation additional cases involved patients with chronic liver disease, encephalopathy, intestinal perforation, sepsis, stroke, paraparesis, rheumatoid arthritis, and hypertension. Specifically, 9 patients had recurrent UTIs, and 6 had a history of hospitalization due to UTIs. The patients developed PUBS after prolonged catheterization, ranging from 25 days to 8 months (median duration: 3 months). In addition, we have also included a Review of Comparative Analysis of PUBS Cases in India [Table 3].
| Characteristics | Number of patients (%) |
|---|---|
| Male: Female | 10:5 |
| Age | 72±8 years |
| Comorbidities | |
| Chronic kidney disease | 8 (53.3) |
| Type 2 diabetes mellitus | 7 (46.7) |
| Hypertension | 6 (40) |
| Chronic constipation | 4 (26.7) |
| Cerebrovascular accident | 4 (26.7) |
| Coronary artery disease | 3 (20) |
| Chronic liver disease | 3 (20) |
| Rheumatoid arthritis | |
| Stricture urethera | |
| Patient | Age/Sex | Comorbidities | Catheterization duration | Urine culture |
|---|---|---|---|---|
| 1 | 65/F | DM, CKD, Constipation | 6 months | No growth |
| 2 | 80/M | CKD stage 4, Hypertension | 8 months | Klebsiella |
| 3 | 70/F | DM, Coronary artery disease CKD stage 3 | 4 weeks | E. coli |
| 4 | 76/M | DM, Diabetic Nephropathy, Constipation | 3 months | No growth |
| 5 | 75/M | DM, Coronary artery disease UTI, Stricture urethra | 25 days | No growth |
| 6 | 62/M | Chronic liver disease, Encephalopathy, Hypertension | 1 month | No growth |
| 7 | 70/M | DM, Diabetic retinopathy, CKD stage 2, Coronary artery disease | 5 months | Polymicrobial |
| 8 | 64/M | COAD, Hypertension, respiratory failure | 20 days | No growth |
| 9 | 72/F | Paraparesis, Chronic constipation | 4 weeks | Klebsiella |
| 10 | 83/M | CKD stage 2, Hypertension, Intracerebral hemorrhage | 8 weeks | No growth |
| 11 | 68/F | Intestinal perforation, Sepsis, Multiorgan failure | 5 months | No growth |
| 12 | 85/M | Hypertension, Stroke, CKD stage 3 | 5 months | No growth |
| 13 | 66/M | DM, Diabetic nephropathy/CKD | 6 months | No growth |
| 14 | 70/M | DM, Encephalopathy (Hypoglycemic) | 6 weeks | Polymicrobial (E. coli, Klebsiella) |
| 15 | 73/F | Rheumatoid arthritis, Hypertension, CKD stage 2 | 8 weeks | E. coli |
DM: Diabetes mellitus, CKD: Chronic kidney disease, UTI: Urinary tract infections, COAD: Chronic obstructive airway disease, PUBS: Purple urine bag syndrome, E. coli: Escherichia coli
| Study/Year | Number of cases | Age/Sex | Comorbidities | Catheterization Duration | Urine Culture | Outcome measure/Management |
|---|---|---|---|---|---|---|
| Ahmad et al. (2020)[5] | 1 | 73 years, F | HTN, Stroke | 6 months | Providencia rettger | Resolution of PUBS/Antibiotics, Catheter change |
| Kumar et al. (2021)[6] | 46 | 34–87 years, M/F | Bedridden, chronic constipation, CVA, Dementia | 7 days–130 days | E. coli, Klebsiella, Pseudomonas | Resolution of PUBS/Antibiotics, Catheter change |
| Ansari et al. (2022)[7] | 1 | 72 years/M | DM/HTN/CVA/CKD | 3 weeks | E. coli/Enterococcus | Resolution of PUBS/Antibiotics, Removal of catheter |
| Present Study (2023–2024) | 15 | 62–85, M/F | DM, CKD, HTN | 1–8 months | E. coli, Klebsiella, Polymicrobial | Resolution of PUBS, No recurrence/Antibiotics, Catheter change, Regular follow-up |
PUBS: Purple urine bag syndrome, HTN: Hypertension, DM: Diabetes mellitus, CKD: Chronic kidney disease, CVA: Cerebrovascular accident, E. coli: Escherichia coli, M: Male, F: Female
Management and outcome
All patients underwent prompt catheter changes and received optimal catheter care to manage PUBS. Antibiotic treatment was tailored to each patient’s specific urine culture results, ensuring targeted therapy against the identified pathogens. Fortunately, no significant complications were reported in any of the 15 patients, highlighting the effectiveness of prompt intervention and appropriate management in preventing further adverse outcomes.
DISCUSSION
PUBS was first reported in 1978, and since then, it has been recognized as a rare and seemingly benign condition.[8] Despite its rarity, studies suggest that PUBS may affect a significant proportion of long-term catheterized patients, with prevalence rates ranging from 8% to 16%.[1] This phenomenon highlights the importance of vigilance and prompt management of UTIs in vulnerable patient populations. The pathogenesis of PUBS is thought to involve the bacterial decomposition of tryptophan in the gut lumen, leading to the production of indoxyl sulfate, which subsequently oxidizes to indigo upon exposure to air.[9-11] Tryptophan, an essential amino acid obtained from dietary sources such as oats, bananas, milk, cheese, bread, chicken, and peanuts,[12] plays a pivotal role in this process. PUBS is often described in patients with specific clinical profiles, including those with alkaline urine, prolonged bed rest, and chronic kidney disease. Catheterization is a major contributor to the risk of developing PUBS, while acidic urine has been linked to increased danger.[13] The syndrome has also been associated with various bacterial species, including Klebsiella pneumoniae, Proteus mirabilis, E. coli, Morganella morganii, and P. aeruginosa.[14-16] Interestingly, data from past literature suggest that PUBS can be precipitated by other intestinal conditions, such as intestinal obstruction.[17-20] This finding underscores the complex interplay between UTIs, catheterization, and systemic health. In the current healthcare landscape, treating catheter-associated urinary tract infections as minor issues is no longer sufficient.[21] The emergence of antimicrobial resistance and the increasing prevalence of chronic conditions underscore the need for enhanced vigilance and proactive management of UTIs. To mitigate the risk of PUBS and related complications, healthcare providers should prioritize the Minimizing catheterization time, Regular catheter changes and Enhanced catheter care, Prompt diagnosis and treatment of UTIs. Particularly for elderly patients, these measures can significantly reduce the risk of PUBS and improve overall health outcomes.[21] By adopting a proactive approach to urinary tract infection management, healthcare providers can optimize patient care and reduce the burden of PUBS and related complications.
- A 70-year-old male patient had type 2 diabetes mellitus, diabetic retinopathy, stroke, left hemiparesis bedridden with urinary catheter in situ and developed purple urine bag syndrome.
- A 72-year-old female patient having Paraparesis and on urine catheter for 4 weeks. She also had a history of chronic constipation and developed purple-colored urine.
CONCLUSIONS
PUBS is a rare and benign condition that serves as a visual indicator of underlying bacteriuria and urinary tract infection. Although PUBS is often asymptomatic and harmless in itself, it should not be dismissed as a trivial matter. Rather, it warrants attention and prompt management to prevent potential complications and exacerbation of underlying health issues. As a manifestation of an ongoing urinary tract infection, PUBS can pose a significant health risk if left untreated, particularly in patients with pre-existing chronic conditions. Therefore, healthcare providers should remain vigilant and take appropriate measures to address the underlying infection and prevent further complications.
Acknowledgment
The authors acknowledge the support of the hospital staff and patients who participated in this study.
Author contribution
Jyoti: Data Curation, Investigation, Writing - Review & Editing
Vikas: Conceptualization, Methodology,
Veenu: Supervision, Validation
Ethical approval
Institutional Review Board approval is not required.
Declaration of patient consent
Patient’s consent not required as patients identity is not disclosed or compromised.
Conflicts of interest
There are no conflicts of interest.
Use of artificial intelligence (AI)-assisted technology for manuscript preparation
The authors confirm that there was no use of artificial intelligence (AI)-assisted technology for assisting in the writing or editing of the manuscript, and no images were manipulated using AI.
Financial support and sponsorship
Nil.
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