Significance of UTI in SCI patients 

Case 1: Bacteriuria in a 51 year old man with MS flare

A 51-year-old male with a history of progressive multiple sclerosis has done well until yesterday when he woke up with significant exacerbation of his symptoms. Usually, he is able to ambulate with a walker, however, yesterday was unable to bear weight, with significant weakness of the lower extremities and have now progressed to the upper extremities. He denies any fevers or chills, cough, or urinary symptoms; however, he has straight intermittently catheterized himself for 2 years. He visited the emergency department.

Vital signs were stable with no fever (temperature 97.9). The anal sphincter tone is good. The prostate is firm and no bogginess and no nodules are appreciated. The CBC reveals an elevated white count at 16.3, 84% neutrophils. Urinalysis does show positive leukocyte esterase and ketones, negative nitrite. A urine culture revealed 50,000 - <100,000 CFU/ml of Klebsiella oxytoca and blood cultures are sent and later proved to be negative. Chest x-ray with PA and lateral views are normal.

Assessments made in the emergency room were: #1. UTI and #2. multiple sclerosis flare. For the patient's UTI, he was started on ciprofloxacin 500 mg IV, and he was admitted to the neurology service. 


Comments and Lessons from This Case: Asymptomatic bacteriuria is a common finding in patients with neurogenic bladder on CIC. About 70% of people on intermittent catheterization are bacteriuric at any given time. We commonly note that such patients are diagnosed as having a UTI and treated by non-urologic physicians. This kind of chronic bacteriuria is not associated with any risk provided bladder pressures are low. There is no need to treat chronic bacteriuria with antibiotics, if bladder pressures are controlled.  If bladder pressures are not controlled treatment with antibiotics will not resolve the problem nor ameliorate the risk of bladder and upper tract damage. Patients with putative “symptomatic infection” need a urodynamic assessment in addition to empiric treatment with antibiotics.  Since the population treated by CIC are bacteriuric most of the time there is no good reason to treat patients with intercurrent problems with antibiotics. There is no hope of permanent eradication of bacteriuira in this population in any case. Thus in this case, 2g of mandelamine was prescribed to be taken morning and night; 1g in the morning and 1g at night as an antibacterial medication for his bladder.  We did this to obviate treatment for prolonged periods with potent antibiotics which is what usually happens to these patients.

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Case 2: A 66 year old male on CIC diagnosed as ‘urosepsis’ 

The patient had a SCI 10 years ago and he had been catheterized every 4 hours using a 14 Fr straight catheter which passes easily without any urinary incontinence in between times of catheterization. He had been on yearly urologic surveillance with stable condition.

Department of Emergency Medicine: The patient was brought in the emergency room today by his wife for altered mental status. The patient was more somnolent than usual today.  His urinalysis appeared to be markedly infected with over 100 white blood cells. He will be started on fluoroquinolone
antibiotic in the department and admitted to the Internal Medicine Service with the diagnosis of “urosepsis”.
Department of Internal Medicine: He had a Foley catheter placed and was admitted to the Medical Service. By the time he got on the floor he had several hundred mL of fluid and his mental status was back to normal.  He had not received any antibiotics. He was extensively evaluated by the Medical Service and the patient was determined to have inappropriate ADH secretion and intermittent confusion related to dehydration rather than true infection.

Department of Urology 1 Month Later: The patient was seen in the ER, determined to have "urosepsis" although he had no temperature change and his pulse and blood pressure were normal.  When the urology team saw him today the patient's wife told us that he has been admitted to several other hospitals in the interim and has been treated for antibiotics for “urosepsis”. He is currently in a nursing home with a Foley catheter in place. This is very poor care for this patient who had really good care at home. I got a consultation from the nursing home so I have written to them saying that this is a long term urology patient with neurogenic bladder related to a SCI.  He had episodes of somnolence and confusion related to dehydration, on the other hand he was treated with optimal management with his catheterization on an intermittent basis rather than chronic indwelling Foley catheter. 

He has been previously managed very well and very expeditiously by CIC at home on a 4 hour basis. His bladder, as determined by several video urodynamic studies is normal as it can be with his current neurological problems and is managed appropriately with CIC. He needs to have this catheter removed as soon as possible. He needs to go back on his CIC protocol at home with his home care providers where he was stable and receiving excellent care.   

Comments and Lessons: Even though he is chronically bacteriuric as are all patients on CIC we did not see any relationship between the episodes of somnolence and mental confusion and his urinary tract. He is always infected and therefore one would have to explain why he is not also always somnolent. Once his dehydration was treated the symptoms resolved. In retrospect he received antibiotics and IV fluids at the time of admission for each of these episodes. It was the fluid resuscitation and not the antibiotics which resulted in the rapid improvement. It is understandable that the medicine service at first associated the antibiotic therapy with the outcome.

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