Prevention Of Urinary Tract Infection In Patients With Spinal Cord Injury

Abstract

Background: Urinary tract infection (UTI) is a major cause of morbidity and mortality in individuals with spinal cord injury (SCI). Altered voiding dynamics, use of urinary drainage catheters, and frequent exposure to antibiotic agents predispose individuals with SCI to recurrent episodes of UTI, often with resistant organisms.

Objective: To evaluate the efficacy of various methods of UTI prevention in the SCI population. These methods include type of bladder management, choice of catheter materials, antiseptic agents, oral antibiotics, and experimental approaches.

Methods: Literature review.

Findings: Choosing a method of bladder management that minimizes the use of a foreign body, yet drains the bladder effectively, is the best available means to reduce the risk of UTI. The chief drawback to antimicrobial-coated catheters, topical or intravesicular antiseptic agents, and prophylactic oral antibiotics is that, over time, bacteria become resistant and overcome the obstacles to bladder invasion. Therefore, antiinfective catheter materials, antibiotics, and antiseptic agents are not beneficial for long-term prevention of UTI in persons with SCI. Novel approaches that avoid the use of antimicrobial agents offer hope for patients with recurrent UTI, but these techniques are still in the experimental stage.

Conclusions: Method of bladder management remains the most influential factor in reducing the risk of UTI in persons with SCI. Experimental approaches that inhibit adhesion and biofilm formation by uropathogens are promising.     

Decreased Incidence of Urinary Tract Infections in Patients with Spinal Cord Injury: Effect of Methenamine

ABSTRACT

This study was designed to determine the effect of methenamine on the frequency of urinary tract infections (UTI) in hospitalized patients after spinal cord injury. The study included 56 patients with neurogenic bladder dysfunction treated with intermittent catheterization. A group of 34 patients was treated with methenamine, 1g twice daily; the other group of 22 patients was the control group receiving no antimicrobial therapy. On a weekly basis urine samples from all patients were obtained for urinalysis and culture. A total of 500 urine samples were analyzed. The patients treated with methenamine had 23.4% positive urine cultures which was significantly lower than 57.5% in the untreated control group (p<0.001). Our data suggest that methenamine therapy is an effective prevention of UTI in paralyzed patients with neurogenic bladder dysfunction during the rehabilitation in hospital. (J Am Paraplegia Soc 1991; 14: 52–54)     

Intermittent Catheterization and Recurrent Urinary Tract Infection in Spinal Cord Injury

Purpose:

To study the association of recurrent symptomatic urinary tract infections (UTIs) with the long-term use of clean intermittent catheterization (CIC) for the management of neurogenic bladder in patients with spinal cord injury (SCI).

Methods:

Retrospective study of 61 SCI patients with neurogenic bladder managed by CIC. Subjects were selected from 210 SCI patients seen at the Yale Urology Medical Group between 2000 and 2010. Medical UTI prophylaxis (PRx) with oral antimicrobials or methenamine/ascorbic acid was used to identify patients with recurrent UTI. The number of positive cultures (≥10³ cfu/mL) within a year prior to starting PRx was used to confirm the recurrence of UTI.

Results:

Fifty-one male and 10 female subjects were managed with CIC. Forty-one (67%) subjects were placed on medical PRx for symptomatic recurrent UTI. Seventeen (28%) subjects had at least 3 positive cultures within the year prior to starting PRx. Fifteen of 20 (75%) subjects not on PRx had no complaints of UTI symptoms in the final year of follow-up.

Conclusion:

Recurrent symptomatic UTIs remain a major complication of long-term CIC in SCI patients. Although CIC is believed to have the fewest number of complications, many SCI patients managed with long-term CIC are started on medical PRx early in the course of management. Future studies are needed to determine the efficacy of routine UTI PRx in these patients as well as determine what factors influence why many patients on CIC experience frequent infections and others do not.     

Orthostatic Hypotension in Spinal Cord Injured Patients

Abstract

Treatment of orthostatic hypotension is an important consideration for many patients with spinal cord injuries, especially those with an injury to the cervical cord. Delay in attainment of an upright sitting posture can cause a delay in the completion of rehabilitation. Although most trials of medications used in the treatment of orthostatic hypotension have been performed on non-spinal cord injured patients, this paper provides a review of both pharmacological and non-pharmacologic means of therapy. Normally, regulation of mean arterial pressure occurs through several different mechanisms; long-term control is via the renal system and short-term control is via the nervous system. These mechanisms will be discussed, as well as causes of orthostatic hypotension in spinal cord injured patients, and the normalization of blood pressure control which generally occurs to some degree following a spinal cord injury. (J Spinal Cord Med 1997; 20:212-217)     

Nitrite and Leukocyte Dipstick Testing For Urinary Tract Infection in Individuals With Spinal Cord Injury

Abstract

Objective: Todetermine sensitivity, specificity, and positive and negative predictive values of nitrite (NIT) and leukocyte esterase (LE) testing in relation to Iabaratory evidence of significant bacteriuria and urinary tract infection (UTI) in persons with spinal cord injury (SCI).

Design: Monthly urine cultures were compared with results of dipstick testing. Setting: Community based.

Methods: Fifty-six people with SCI were evaluated on a monthly basis with dipstick testing for NIT and LE as weil as urine cultures. Participants reported whether they believed that they had a UTI and, if so, whether they were treated for the UTI and what symptoms they had experienced.

Results: The sensitivity rate for the most comprehensive criteria-defined as positive NIT test, a positive LE positive, or both a positive NIT test and positive LE test-was 0.64 and the specificity rate was only 0.52. No singletype ofbacteria was found to occur in more than 3 0% of the urine samples.

Conclusion: Reliance on dipstick testing for NIT and LEin individuals with SCI can Iead to high rates of overtreatment for UTI, given the fact that regular catheterization is associated with significant bacteriuria. lndividuals with SCI should be evaluated with urine culture to ensure proper treatment.     

Stroke in the Spinal Cord Injured

ABSTRACT

Advances in treatment of patients with spinal cord injury (SCI) have contributed to prolongation of their life expectancy. As a result, this population is becoming more prone to the diseases commonly associated with advanced age and a sedentary lifestyle. The purpose of this study was to test the hypothesis that the SCI population has an increased incidence of stroke, and to identify stroke risk factors unique to SCI patients. A retrospective, computer assisted medical chart review of all admissions from 1980 to 1990 was conducted. Of more than one thousand patients who had a stroke and two thousand paraplegic/quadriplegic patients, we identified only two instances involving stroke in patients with traumatic SCI. We conclude that the SCI population does not appear to have a higher incidence of stroke, although further prospective studies involving a larger patient population are recommended. Possible protective factors and causes for under-reporting stroke in the SCI population are discussed. (J Am Paraplegia Soc; 17: 36–38)     

Selecting the Appropriate Urinary Diversion Procedure in the Spinal Cord Injured: A Poignant Reminder

abstract

Lower urinary tract reconstruction has been performed on the spinal injured population at our institution since 1988. Careful pre-operative evaluation including a detailed history, physical examination and radiographic and/or urodynamic studies are usually obtained to determine which type of procedure would be most beneficial for each individual patient. Typically, patients receive either a cutaneous (i.e., Kock or Indiana) diversion or undergo a form of bladder augmentation (usually ileocystoplasty). Pre-operative findings and the patient’s history are carefully considered prior to choosing the appropriate procedure. Occasionally, a particular finding influences the decision. We describe a patient who received a hemi-Kock ileocystoplasty with a continent abdominal stoma who, in retrospect, would have benefitted from a supravesical diversion. (J Spinal Cord Med 19:197–200)     

The Use of Urine Cytology for Diagnosing Bladder Cancer in Spinal Cord Injured Patients

Purpose

The diagnosis of bladder cancer in spinal cord injured patients is complicated by inflammatory changes caused by long-term indwelling catheters, which make cystoscopic followup difficult. We evaluated cytology as an aid in diagnosing bladder cancer in spinal cord injured patients.

Materials and Methods

The charts of 208 spinal cord injured patients were reviewed retrospectively from January 1988 to July 1995 to define the value of cytology in the diagnosis of bladder cancer in this population. In all patients at least 1 urine cytology study was done less than 3 months before bladder biopsy. We examined 272 bladder biopsies (several patients underwent more than 1 biopsy at least 1 year apart) with 1 to 6 cytology studies done before biopsy.

Results

Cytology results were classified as negative-no malignant cells, inflammation or benign urothelial cells, reactive-atypia or atypical reactive and suspicious-atypical suspicious, keratinizing squamous metaplasia, suspicious for cancer, cancer of dysplastic. A total of 960 cytology specimens was obtained before the 272 biopsies (average 3 before each biopsy). Of 17 patients with cancer 12 had at least 1 prior suspicious urine cytology result. The sensitivity and specificity of cytology were 71 and 97%, respectively, when evaluating only patients with suspicious findings.

Conclusions

The high sensitivity and specificity of multiple cytology studies in this population suggest that cytology is a useful adjunct to improve the detection of bladder cancer in spinal cord injured patients with chronic (longer than 5 years) indwelling catheters. We recommend a minimum of yearly cytology in all high risk spinal cord injured patients with subsequent biopsies in all patients with any suspicious finding.     

尾静脉注射bFGF对大鼠脊髓损伤的早期影响

目的:比较不同途径应用碱性成纤维细胞生长因子(basicfibroblastgrowthfactor,bFGF)对大鼠脊髓损伤早期水、钙、镁离子的影响,探讨静脉应用bFGF的可行性。方法:AllenWD(Weightdrop)技术,以10g×25cm致伤力造成大鼠T8急性脊髓不完全损伤,不同途径用药比较。术后2h、6h及24h切取伤区脊髓组织检测水、钙、镁离子变化。结果:受损伤脊髓组织水含量增多,钙离子水平增高,镁离子水平下降,而蛛网膜下腔应用bFGF及尾静脉注射bFGF均能明显改变上述变化。结论:脊髓损伤早期静脉应用bFGF同样对脊髓损伤具有保护作用。     

Fertility of Spinal Cord Injured Males: Effect of Genitourinary Infection and Bladder Management on Results of Electroejaculation

ABSTRACT

Thirty-eight men undergoing electroejaculation (EEJ) procedures for anejaculatory infertility were examined for the presence or absence of infection in urine and semen. In 29 spinal cord injury patients, a high incidence of infected urine and infected semen (41% and 56%, respectively) was seen, in contrast to patients with normal bladder function (0% and 11 %).

Urinary infection was associated with slightly lower sperm quality and lower pregnancy rates (10% vs 30% in the presence of sterile urine). Semen infection had no effect on sperm counts or pregnancy rates. If intermittent self-catheterization (ISC) was used to empty the neurogenic bladder, slightly better sperm quality was seen, the total failure rate was less, and much better pregnancy rates (44%) resulted than for patients using an alternative bladder management (7%).

Antibiotics did not reduce the incidence of urine or semen infection, but did improve sperm counts slightly. Continuous prophylaxis was associated with bacterial resistance to many oral antibiotics and had no advantage over a short course of antibiotics prior to the procedure.

Despite the above associations, the sperm quality in our patient population was never normal compared with that of men who ejaculate normally. We conclude that the low sperm quality seen in electroejaculation specimens from spinal cord injured males is not due entirely to infection or to the type of bladder management. Short courses of antibiotics, instead of continuous antibiotic prophylaxis, may be beneficial. Intermittent catheterization is superior to other methods of neurogenic bladder management in maintaining the fertility of spinal cord injured men.     

The Prevention and Management of Urinary Tract Infections Among People With Spinal Cord Injuries

ABSTRACT

The Urinary Tract Infection Consensus Conference brought together researchers, clinicians, and consumers to arrive at consensus on the best practices for preventing and treating urinary tract infections in people with spinal cord injuries; the risk factors and diagnostic studies that should be done; indications for antibiotic use; appropriate follow-up management; and needed future research. Urinary tract infection (UTI) was defined as bacteriuria (102 bacteria/ml of urine) with tissue invasion and resultant tissue response with signs and/or symptoms. Asymptomatic bacteriuria represents colonization of the urinary tract without symptoms or signs.

Risk factors include: over-distention of bladder, vesicoureteral reflux, high pressure voiding, large post-void residuals, presence of stones in urinary tract, and outlet obstruction. Possible physiologic/structural, behavioral, and demographic risk factors were identified also. Indwelling catheterization, including suprapubic, and urinary diversion are the drainage methods most likely to lead to persistent bacteriuria. Infection risk is reduced with intermittent catheterization, but more severely disabled people who require catheterization by others are at greater risk for UTIs. Clean self-intermittent catheterization does not pose a greater risk of infection than sterile self-intermittent catheterization and is much more economic. However, care must be given to proper cleansing of reusable catheters.

Quantitative urine-culture criteria for the diagnosis of bacteriuria include: catheter specimens from individuals on intermittent catheterization ≥10² cfu/ml; clean-void specimens from catheter-free males using condom collection devices ≥10⁴ cfu/ml; and specimens from indwelling catheters of any detectable concentration. Dip stick screening tests may offer promise as an early warning system of UTI since they can be self-administered.

Symptomatic UTI should be treated with antibiotics for 7 to 14 days. Longer courses have not been beneficial. In patients with symptomatic UTIs, it is not necessary to wait for the results of cultures before starting treatment. Asymptomatic bacteriuria need not be treated with antibiotics. There is little evidence presently to support the use of antibiotics to prevent infections.

Following a recent episode of febrile UTI, possible contributing prior events should be reviewed. The upper tracts should be evaluated (imaging studies) to identify possible abnormalities. A common concern among people with spinal cord injuries is that physicians will alter bladder management programs without regard to lifestyle needs. Social/vocational flexibility may be more important to them than a state-of-the-art bladder management program.

Future research should focus on obtaining more representative samples and investigate psycho-social-vocational implications as well as additional clinical-medical factors.     

Cisapride for Constipation in Spinal Cord Injured Patients: A Preliminary Report

Abstract

Chronic constipation in patients with spinal cord injury (SCI) has significant impact on quality of life. To measure baseline clinical functioning, colonic transit time and anorectal manometry and the effect of cisapride on these clinical and physiological parameters, we studied 12 SCI patients. Patients initially received baseline clinical scoring, measurement of colonic transit time and anorectal manometry. Patients then received cisapride 20 mg orally three times each day. After one and three months of cisapride therapy, all measurements were repeated. The mean duration of cisapride treatment was 5.2 months. Six of 12 (50 percent) reported that symptoms of constipation improved. No patient had worsening of symptoms. Prior to cisapride treatment, 23 percent of patients passed colonic transit markers by day five and 57 percent by day seven; baseline anal manometry revealed variable resting and squeeze pressures. After treatment, 33 percent of patients passed their colonic transit markers by day five and 71 percent by day seven. Six of 12 (50 percent) demonstrated a 10 percent or more increase in resting anal canal pressures. We conclude that about 50 percent of SCI patients have subjective improvement in constipation after cisapride therapy. Cisapride appears to improve both colonic and anorectal function. (J Spinal Cord Med, 8:240–244)     

Effect of External Urinary Collection System on Colonization and Urinary Tract Infections with Pseudomonas and Klebsiella in Men with Spinal Cord Injury

ABSTRACT

Urinary tract infection of men with spinal cord injuries has been associated with a high incidence of colonization of the patients with gram-negative bacilli. We have examined the factors influencing colonization of 119 patients with Pseudomonas and Klebsiella and studied methods of reducing this colonization. The urethra, perineum, rectum, and drainage bag of all patients were cultured on selective media at two week intervals until discharge. The use of the external urinary collection system (EUCS) was discontinued in a group of patients at night, in an attempt to reduce colonization. Pseudomonas and Klebsiella were isolated from one or more body sites in 65 percent and 69 percent of total culture days. The urethra, perineum, rectum, and drainage bags were reservoirs of Pseudomonas and Klebsiella in men with spinal cord injuries, even in the absence of urinary tract infections. The EUCS proved to be an important factor influencing colonization. Pseudomonas and Klebsiella colonization was higher in patients using the EUCS. Removal of the EUCS at night reduced urethral colonization with Pseudomonas, but did not significantly reduce urethral colonization with Klebsiella.

The prevalence of bacteriuria with Pseudomonas and Klebsiella was not significantly influenced by the use of the EUCS.     

泌尿系肿瘤患者尿路感染危险因素Logistic回归分析

目的探讨引起泌尿外科肿瘤住院患者尿路感染的危险因素。方法回顾性分析了200例泌尿外科肿瘤住院病历,将肿瘤合并尿路感染者作为观察组,按1∶1选择同期无尿路感染泌尿外科患者作为对照组,对可能的影响因素先进行了单因素V~2、t检验;然后将单因素分析差异有统计学意义的变量进行多元逐步Logistic回归分析。结果 200例患者中合并尿路感染26例,发生率为13%;单因素分析了7个变量是尿路感染有影响的危险因素(P0.05),采用了Logistic回归分析,筛选出独立危险因素,按OR值的大小,依次为年龄大、伴有创诊治措施、合并其他的疾病。结论泌尿外科肿瘤住院患者尿路感染的发生率较高,影响尿路感染因素较多,应针其因素给予针对性的预防措施。     

手术减压时间对损伤脊髓轴索病理和损伤区面积的影响

目的 探讨大鼠脊髓损伤后手术减压时间对大鼠脊髓轴索病理和损伤区面积的影响。方法 将动物分为两组：大鼠脊髓挫伤2h手术减压组（A组）,大鼠脊髓挫伤8h手术减压组（B组）。手术后1、3、7、14、28d进行轴索病理变化的观察并测量脊髓损伤面积,采用计算机图像分析技术,进行定量分析。计算Tarlv评分并检测感觉诱发电位（SEP）和运动诱发电位（MEP）。结果 图象分析发现：脊髓损伤后B组轴索丢失明显多于A组。脊髓损伤面积B组亦明显大于A组;大鼠后肢功能Tarlv评分和电生理检查也有类似的变化趋势。结论 大鼠脊髓损伤后早期手术减压对损伤的大鼠脊髓轴索有保护作用,能减少脊髓损伤面积,并促进大鼠后肢功能恢复。