Guideline for Treatment of UTI in SCI  

UTI in SCI patients

  • When catheterization is long-term (> 10 days), bacteriuria eventually occurs in almost all patients [Warren 1982a].
  • Periods of bacteriuria may alternate with periods of sterile urine, or bacteriuria may become chronic; in both instances the infecting strains often change [Warren 1982a].
  • Bacteriuria is frequently polymicrobial [Warren 1982a; Warren 1987]: Escherichia coli, Pseudomonas spp., Klebsiella spp., Proteus spp., Serratia spp., Providencia spp., enterococci, and staphylococci are the most frequently isolated bacteria in urine specimens taken from individuals with SCI [Biering-Sorensen 2001]
  • A recurrent problem is catheter encrustation and eventual obstruction. Periodic catheter changes may prevent these complications. The encrustation is a biofilm which becomes coated with calcific material related to the metabolism of urea splitting organisms: struvite.
  • Bacteriuria was found equally in men and women, while clinical UTI was significantly higher among women [Bakke 1993].
  • For more information, please refer to this this

Treatment of UTI in SCI patients

  • Asymptomatic bacteriuria:
    • Need not be treated with antibiotics [NIDRRCS 1992; Garcia Leoni 2003].
    • Antibacterial drugs should not be used to prevent or treat an asymptomatic infection of the urine [Kunin 1985]
    • There are no data to support or justify treatment of asymptomatic bacteriuria. [Jayawardena 2004]
    • Unfortunately many patients with neurogenic vesical dysfunction with or without catheters are treated intermittently or continuously with antibacterial agents to eradicate bactiuria, which is quite impossible. This then delays assessment of lower urinary tract function in these patients which is more important than the treatment of chronic bacterial contamination of the urine.
    • For case study, please refer here
  • Symptomatic UTI:
    • Symptomatic UTI warrants therapy in all patients [Garcia Leoni 2003].
    • Guidelines for selecting antimicrobial agents in SCI patients are similar to guidelines for the treatment of complicated urinary infections in the general population. Characteristics of the quinolones make them well suited to treating UTI in the SCI patient [Siroky 2002]
    • Symptomatic infections are usually treated for 7 to 14 days. There is no good data to prove this length of treatment is required. We routinely use only 3 days and sometimes only 2 days hoping to avoid emergence of multi resistant organisms as recolonization is inevitable. Treatment longer than 7 days has not been found to be beneficial [NIDRRCS 1992;
    • In patients with symptomatic UTIs, it is not necessary to wait for the results of cultures before starting treatment.
    • UTIs associated with fever, flank pain, pyelonephritis, upper tract stone disease and /or positive blood cultures are not common. When these occur, more prolonged treatment is recommended to prevent milliary spread of bacterial organisms. An apparently febrile UTI is much more common in high cervical lesions than in paraplegic patients suggesting that other causes of fever can be misidentified as urosepsis since chronic bacteriuria is present in virtually all SCI patients managed by catheters or CIC. For a case review, please refer to this (
    • Patients with symptomatic UTI especially that associated with fever, and a positive bladder culture must be evaluated by urodynamic testing. This almost never happens in patient with low pressure bladder dysfunction on CIC and if it occurs in catheterized patients it is terelated to the catheter and not simply a problem of an “infection”.

Prevention of UTI in SCI patients

  • Frequent exposure to antibiotics increases the risk of infection by resistant organisms.
  • The prevention of bacteriuria and associated complications in patients undergoing long-term catheterization has been largely unsuccessful and, therefore, there is little evidence presently to support the use of antibiotics to prevent infections [Warren 1982b; NIDRRCS 1992].
  • Treating episodes of asymptomatic bacteriuria does not reduce the complications of bacteriuria in patients undergoing long-term catheterization [Warren 1982b].
  • CIC has resulted in lower rates of bacteriuria than long-term indwelling catheterization in studies with historical controls [Warren 1978].
  • In patients undergoing CIC, bacteriuria may be reduced by bladder irrigation with a solution of neomycin and polymyxin or by oral methenamine, nitrofurantoin, or trimethoprim-sulfamethoxazole prophylaxis [Kuhlemeier 1985; Warren 1987]. There is no data which proves that this is beneficial.
  • Antibacterial prophylaxis significantly reduced the probability of laboratory infection but not the probability of clinical infection [Maynard 1984]. Not only that, the incidence of positive blood cultures in patients thought to have urosepsis during acute rehabilitation, in the unit referred to in the reference cited, was 0, and the prevalence of UTI determined by colony count precisely the same as that in the asymptomatic population. An accurate end point for the determination of the effect of any treatment on UTI is not the presence or absence of bacteriuira, but freedom from symptomatic, clinically significant, infection. That study has never been done and the patient numbers required to do it would be enormous. On the other hand there is very good long term data that proves a low pressure urinary system is highly resistant to clinically significant infection. Moreover creation of a low pressure bladder resolves problems with infection related complications despite persistent chronic bacteriuria [Flood 1995]. For more information, please refer to this

Controversy in the Efforts for UTI Prophylaxis

  • Systemic antimicrobial prophylaxis
    • Trimethoprimsulfamethoxazole or fluoroquinolones: conflicting results are reported and there is no accurate way to dertermine true efficacy.
    • Should not be used in individuals with SCI/D and indwelling catheters [Biering-Sorensen 2001]
    • Controversial in individuals with SCI/D using CIC or other methods of bladder emptying [Biering-Sorensen 2001]
  • Bladder irrigation:
    • Periodic catheter irrigation with normal saline: is unproven technique to prevent bacteriuria [Muncie 1989]
    • Neomycin/polymyxin: While bladder irrigation with this solution did not change the type of organism, it was effective in changing the resistance of most organisms. Not a good result [Linsenmeyer 1999]
  • Methenamine mandelate (oral):
    • Production of urine formaldehyde in a low pH urine
    • Effective in preventing urinary colonization in patients with neurogenic bladder dysfunction who were on a program of CIC [Kevorkian 1984; Krebs 1984].
    • Of limited value in asymptomatic chronic bacteriuric patients with indwelling catheters [Nahata 1982]
  • Cranberry juice (oral):
    • No convincing effect, need for appropriate placebo-controlled trial to confirm this [Jepson 2000]
    • Cranberry tablets were not found to be effective at changing urinary pH or reducing bacterial counts, urinary WBC counts, or UTIs in individuals with neurogenic bladders [Linsenmeyer 2004]
  • Ascorbic acid:
    • Only useful as adjuvant therapy together with other antibacterial drugs [Murphy 1965; Stover 1980].
  • Silver-coated urinary catheters:
    • A formal meta-analysis of eight randomized controlled trials, and found that these catheters were not significantly better than control catheters, but that silver alloy catheters were significantly more effective in preventing bacteriuria than silver oxide catheters [Saint 1998]
    • Silver-impregnated catheters failed to demonstrate the prevention of catheter-associated bacteriuria. It has also shown a significantly increased incidence of bacteriuria in male patients and a significantly increased occurrence of staphylococcal bacteriuria [Riley 1995]
  • High urine output:
    • No effect [Gibson 1978]
  • Meatal hygiene or perineal washing
    • Ineffective [Cravens 2000]
    • However, general cleanliness and local hygiene should be “encouraged” for prevention of UTI [Biering-Sorensen 2001]
  • Frequent catheter change: ineffective [Cravens 2000]
  • Antimicrobial agents in the drainage bag: No effect [Saint 1999]
Key Points of This Section
  • Chronic bacteriuria is very common in SCI patients including those on intermittent catheterization.
  • If bladder storage (and where existent voiding pressures) are controlled within fairly narrow limits symptomatic infection is rare and detectable urinary tract damage, urosepsis, or tissue loss even more rare.
  • Control of bladder pressure and preservation of normal storage function is not possible in patients with indwelling catheters and neither is treatment of bacteriuira in this patient population effective or prophylactic.

References

  • Bakke A, Vollset SE. Risk factors for bacteriuria and clinical urinary tract infection in patients treated with clean intermittent catheterization. J Urol. 1993 Mar;149(3):527-31.
  • Biering-Sorensen F, Bagi P, Hoiby N. Urinary tract infections in patients with spinal cord lesions: treatment and prevention. Drugs. 2001;61(9):1275-87.
  • Cravens DD, Zweig S. Urinary catheter management. Am Fam Physician. 2000 Jan 15;61(2):369-76.
  • Donovan WH, Stolov WC, Clowers DE, Clowers MR. Bacteriuria during intermittent catheterization following spinal cord injury. Arch Phys Med Rehabil 1978;59:351-357.
  • Flood HD, Malhotra SJ, O'Connell HE, Ritchey MJ, Bloom DA, McGuire EJ. Long-term results and complications using augmentation cystoplasty in reconstructive urology. Neurourol Urodyn. 1995;14(4):297-309.
  • Garcia Leoni ME, Esclarin De Ruz A. Management of urinary tract infection in patients with spinal cord injuries. Clin Microbiol Infect. 2003 Aug;9(8):780-5.
  • Gibson CJ, Moon AH. Urinary output and incidence of acute urinary tract infection in patients with indwelling bladder catheters.Arch Phys Med Rehabil. 1978 Jan;59(1):17-20.
  • Jayawardena V, Midha M. Significance of bacteriuria in neurogenic bladder. J Spinal Cord Med. 2004;27(2):102-5.
  • Jepson RG, Mihaljevic L, Craig J. Cranberries for preventing urinary tract infections.Cochrane Database Syst Rev. 2000;(2):CD001321.
  • Kevorkian CG, Merritt JL, Ilstrup DM. Methenamine mandelate with acidification: an effective urinary antiseptic in patients with neurogenic bladder. Mayo Clin Proc. 1984 Aug;59(8):523-9.
  • Krebs M, Halvorsen RB, Fishman IJ, Santos-Mendoza N. Prevention of urinary tract infection during intermittent catheterization. J Urol. 1984 Jan;131(1):82-5.
  • Kuhlemeier K, Stover SL, Lloyd LK. Prophylactic antibacterial therapy for preventing urinary tract infections in spinal cord injury patients. J Urol 1985;134:514-517.
  • Kunin CM, Steele C. Culture of the surfaces of urinary catheters to sample urethral flora and study the effect of antimicrobial therapy. J Clin Microbiol. 1985 Jun;21(6):902-8.
  • Linsenmeyer TA, Harrison B, Oakley A, Kirshblum S, Stock JA, Millis SR. Evaluation of cranberry supplement for reduction of urinary tract infections in individuals with neurogenic bladders secondary to spinal cord injury. A prospective, double-blinded, placebo-controlled, crossover study. J Spinal Cord Med. 2004;27(1):29-34.
  • Linsenmeyer TA, Jain A, Thompson BW. Effectiveness of neomycin/polymyxin bladder irrigation to treat resistant urinary pathogens in those with spinal cord injury. J Spinal Cord Med. 1999 Winter;22(4):252-7.
  • Maynard FM, Diokno AC. Urinary infection and complications during clean intermittent catheterization following spinal cord injury. J Urol. 1984 Nov;132(5):943-6.
  • Muncie HL Jr, Hoopes JM, Damron DJ, Tenney JH, Warren JW. Once-daily irrigation of long-term urethral catheters with normal saline. Lack of benefit. Arch Intern Med. 1989 Feb;149(2):441-3.
  • Murphy FJ, Zelman S, Mau W. Ascorbic acid as a urinary acidifying agent. 2. Its adjunctive role in chronic urinary infection.J Urol. 1965 Sep;94(3):300-3.
  • Nahata MC, Cummins BA, McLeod DC, Schondelmeyer SW, Butler R. Effect of urinary acidifiers on formaldehyde concentration and efficacy with methenamine therapy. Eur J Clin Pharmacol. 1982;22(3):281-4.
  • Riley DK, Classen DC, Stevens LE, Burke JP. A large randomized clinical trial of a silver-impregnated urinary catheter: lack of efficacy and staphylococcal superinfection. Am J Med. 1995 Apr;98(4):349-56.
  • Saint S, Elmore JG, Sullivan SD, Emerson SS, Koepsell TD. The efficacy of silver alloy-coated urinary catheters in preventing urinary tract infection: a meta-analysis. Am J Med. 1998 Sep;105(3):236-41.
  • Saint S, Lipsky BA. Preventing catheter-related bacteriuria: should we? Can we? How? Arch Intern Med. 1999 Apr 26;159(8):800-8.
  • Siroky MB. Pathogenesis of bacteriuria and infection in the spinal cord injured patient. Am J Med. 2002 Jul 8;113 Suppl 1A:67S-79S.
  • Stover SL, Fleming WC. Recurrent bacteriuria in complete spinal cord injury patients on external condom drainage. Arch Phys Med Rehabil. 1980 Apr;61(4):178-82.
  • The prevention and management of urinary tract infections among people with spinal cord injuries. National Institute on Disability and Rehabilitation Research Consensus Statement. January 27-29, 1992, J Am Paraplegia Soc. 1992 Jul;15(3):194-204.
  • Warren JW, Tenney JH, Hoopes JM, Muncie HL, Anthony WC. A prospective microbiologic study of bacteriuria in patients with chronic indwelling urethral catheters. J Infect Dis 1982a;146:719-723.
  • Warren JW, Anthony WC, Hoopes JM, Muncie HL Jr. Cephalexin for susceptible bacteriuria in afebrile, long-term catheterized patients. JAMA. 1982b Jul 23;248(4):454-8.
  • Warren JW. Catheter-associated urinary tract infections. Infect Dis Clin North Am 1987;1:823-854.

©2007 University of Michigan - UTI

Home Link to UMHS