Inconsistency in the Definition of Urinary Tract Infection after Intravesical Botulinum Toxin A Injection: A Systematic Review

Antibiotic prophylaxis for onabotulinum toxin A injections: systematic review and meta-analysis

INTRODUCTION AND HYPOTHESIS

To our knowledge, there are no evidence-based recommendations regarding the optimal prophylactic antibiotic regimen for intradetrusor onabotulinum toxin type A (BTX) injections. This systematic review and meta-analysis was aimed at investigating the optimal prophylactic antibiotic regimen to decrease urinary tract infection (UTI) in patients undergoing BTX for overactive bladder syndrome (OAB).

METHODS

A systematic search of MEDLINE, Embase, CINAHL, and Web of Science was conducted from inception through 30 June 2022. All randomized controlled trials and prospective trials with > 20 subjects undergoing BTX injections for OAB in adults that described prophylactic antibiotic regimens were included. Meta-analysis performed to assess UTI rates in patients with idiopathic OAB using the inverse variance method for pooling.

RESULTS

A total of 27 studies (9 randomized controlled trials, 18 prospective) were included, representing 2,100 patients (69% women) with 19 studies of idiopathic OAB patients only, 6 of neurogenic only, and 2 including both. No studies directly compared antibiotic regimens for the prevention of UTI. Included studies favor the use of antibiotics in patients with idiopathic OAB and favor continuing antibiotics for 2-3 days after the procedure for prevention of UTI. Given the heterogeneity of the data, direct comparisons of antibiotic type or duration could not be performed. Meta-analysis found a 10% UTI rate at 4 weeks and 15% at 12 weeks post-injection.

CONCLUSIONS

Although there are insufficient data to support the use of a specific antibiotic regimen, available studies favor the use of prophylactic antibiotics for 2-3 days in idiopathic OAB patients undergoing BTX injection. Future trials are needed to determine the optimal regimens to prevent UTI in patients undergoing BTX for OAB.

Comparison of Urinary Tract Infection Incidence Following Intradetrusor OnabotulinumtoxinA in Office Versus Operating Room Settings

IMPORTANCE

Urinary tract infection (UTI) is a known complication of intradetrusor onabotulinumtoxinA (BTX) injection. However, whether administering intradetrusor BTX in different clinical settings affects the risk of postprocedural UTI has not been investigated.

OBJECTIVES

The objective of this study was to assess differences in the incidence of postprocedural UTI in women who received intradetrusor BTX in an outpatient office versus an operating room (OR).

STUDY DESIGN

We performed a retrospective chart review of intradetrusor BTX procedures at a single institution between 2013 and 2020. Demographic data, comorbidities, and perioperative data were abstracted. The primary outcome was UTI defined as initiation of antibiotics within 30 days following BTX administration based on clinician assessment of symptoms and/or urine culture results. Univariate analysis of patients with and without UTI was performed.

RESULTS

A total of 446 intradetrusor BTX procedures performed on female patients either in an outpatient office (n = 160 [35.9%]) or in an OR (n = 286 [64.1%]) were included in the analysis. Within 30 days of BTX administration, UTI was diagnosed after 14 BTX procedures (8.8%) in the office group and 29 BTX procedures (10.1%) in the OR group ( P = 0.633). De novo postprocedural urinary retention occurred in more women who were treated in the office than in the OR (13 [9.6%] vs 3 [1.3%], P < 0.001).

CONCLUSIONS

Selecting the appropriate setting for BTX administration is dependent on multiple factors. However, the clinical setting in which intradetrusor BTX is administered may not be an important factor in the development of postprocedural UTI, and further research is warranted.

Contemporary management considerations of urinary tract infections for women with spina bifida

INTRODUCTION AND HYPOTHESIS

Urinary tract infections (UTIs) are one of the leading health concerns and causes of hospitalization for adults with spina bifida (SB). The risk factors, evaluation, management, and prevention of UTIs in women with SB must take into consideration their unique pelvic anatomy and function as well as the desire for pregnancy or the occurrence UTI during pregnancy. This article reviews published literature regarding this topic and offers recommendations for UTI evaluation, management, and prevention in the context of the unique pelvic floor health needs of women with SB.

METHODS

A systematic review was conducted using the following keywords: spinal dysraphism, spina bifida, myelomeningocele, meningocele, urinary tract infections, females, and adults. Articles were included if they were in English, published during or after 2000, peer reviewed, included women with spina bifida aged 18 or greater, and included outcomes related to urinary tract infection.

RESULTS

No articles met inclusion criteria.

CONCLUSION

As no articles were found based on the initial search criteria, articles pertaining to neurogenic bladder UTI risks, evaluation, and management were discussed to develop consensus recommendations for the unique care of UTIs in women with SB.

Prophylactic intravenous gentamicin with sedation-free cystoscopic injection of BoNT-A: No demonstrable adverse extravesical neuromuscular effects in a pilot safety study of 220 idiopathic overactive bladder patients

Objectives:

To determine whether administration of single dose prophylactic intravenous gentamicin prior to intravesical injection of botulinum toxin type A (BoNT-A) is associated with adverse extravesical neuromuscular effects in idiopathic overactive bladder syndrome.

Patients and methods:

A retrospective analysis of 220 consecutive idiopathic overactive bladder patients following sedation-free flexible cystoscopic injection of intravesical BoNT-A. All patients received a single dose of intravenous gentamicin (160 mg) followed by 100-200 IU of BoNT-A. They were followed up at intervals to determine whether they had experienced any adverse extravesical neuromuscular side effects.

Results:

None of our patients developed adverse extravesical neuromuscular side effects from intravesical botulinum injections with concomitant administration of intravenous gentamicin.

Conclusion:

Single dose intravenous gentamicin is safe to use as a prophylaxis for intravesical BoNT-A injections of 200 IU or below in idiopathic overactive bladder patients.

Level of evidence:

Not applicable.

Does a Recent Urinary Tract Infection Increase the Risk of Postprocedure Urinary Tract Infection After Onabotulinum Toxin A?

OBJECTIVES

The objective of this study was to evaluate the risk of postprocedure urinary tract infection (UTI) after injection of onabotulinum toxin A (BTX-A) in women who had a UTI within 30 days before procedure.

METHODS

This was a retrospective cohort study of women who underwent their first injection of BTX-A from 2010 to 2016. Two cohorts were identified: (1) recent UTI (within 30 days before injection) and (2) no recent UTI. Our primary outcome was UTI within 90 days after BTX-A. Continuous variables were analyzed using the Wilcoxon rank sum test, and categorical variables were analyzed using Fisher exact or χ2 tests.

RESULTS

One hundred sixty-six women underwent their first BTX-A injection. Twenty-five (15%) had a recent UTI and 141 (85%) did not. Women with a recent UTI were more likely to have a subsequent infection (52% vs 26%, P < 0.01). However, in a logistic regression model, controlling for history of recurrent UTI, age, history of diabetes mellitus, periprocedural antibiotics, and urinary retention requiring catheterization, the association between having a recent UTI, and a subsequent UTI was no longer significant (adjusted odds ratio, 1.98; 95% confidence interval, 0.60-6.50; P = 0.26).

CONCLUSIONS

Performing a first injection of BTX-A within 30 days of a UTI does not increase the odds of postprocedure UTI. Therefore, BTX-A therapy does not need to be delayed after a recent UTI.

The current scope of healthcare-associated infection surveillance activities in hospitalized immunocompromised patients: a systematic review

BACKGROUND

Immunocompromised patients are at increased risk of acquiring healthcare-associated infections (HAIs) and often require specialized models of care. Surveillance of HAIs is essential for effective infection-prevention programmes. However, little is known regarding standardized or specific surveillance methods currently employed for high-risk hospitalized patients.

METHODS

A systematic review adopting a narrative synthesis approach of published material between 1 January 2000 and 31 March 2018 was conducted. Publications describing the application of traditional and/or electronic surveillance of HAIs in immunocompromised patient settings were identified from the Ovid MEDLINE®, Ovid Embase® and Elsevier Scopus® search engines [PROSPERO international prospective register of systematic reviews (registration ID: CRD42018093651)].

RESULTS

In total, 2708 studies were screened, of whom 17 fulfilled inclusion criteria. Inpatients diagnosed with haematological malignancies were the most-represented immunosuppressed population. The majority of studies described manual HAI surveillance utilizing internationally accepted definitions for infection. Chart review of diagnostic and pathology reports was most commonly employed for case ascertainment. Data linkage of disparate datasets was performed in two studies. The most frequently monitored infections were bloodstream infections and invasive fungal disease. No surveillance programmes applied risk adjustment for reporting surveillance outcomes.

CONCLUSIONS

Targeted, tailored monitoring of HAIs in high-risk immunocompromised settings is infrequently reported in current hospital surveillance programmes. Standardized surveillance frameworks, including risk adjustment and timely data dissemination, are required to adequately support infection-prevention programmes in these populations.

Safety of Intradetrusor OnabotulinumtoxinA (BTX-A) Injection in the Asymptomatic Patient With a Positive Urine Dip

OBJECTIVE

To evaluate differences in adverse events (AE) in asymptomatic patients with a positive urine dip (UD) at time of intradetrusor onabotulinumtoxinA (BTX-A) injection vsthose with a defined negative UD.

MATERIALS AND METHODS

All intradetrusor BTX-A injections were retrospectively reviewed at a single institution between 2016 and 2018. Exclusion criteria included an indwelling catheter, recent positive urine culture, recent antibiotic course, or absence of UD on the day of injection. A positive UD was defined using 7 different definitions with varying combinations of any level of positive blood, leukocyte esterase, or nitrite. Negative UDs were defined those excluded from the positive UD group. We compared multiple positive UD-defined groups to their respective negative UD cohorts with regards to outcomes and demographics.

RESULTS

A total of 212 patients underwent 335 cycles of BTX-A injections over a 2-year period. The average age was 65 years (range: 21-90). The majority received 100 units (73%) of BTX-A for a non-neurogenic diagnosis (73%). The overall rate of AEs, urinary tract infection, and urinary retention was 14.6%, 9%, and 3%, respectively. In all groups, the most common AE was urinary tract infection followed by urinary retention. There were no major Clavien-Dindo-defined complications. There was no statistically significant difference in the total or categorical AE rates between positive and negative UD groups using all 7 definitions of a positive UD (P = .05-1.0).

CONCLUSION

These data do not support the practice of obtaining a preprocedure UD in asymptomatic patients undergoing intradetrusor BTX-A injection for any indication; test results are unable to predict outcomes or AEs.

Adult Neurogenic Lower Urinary Tract Dysfunction and Intermittent Catheterisation in a Community Setting: Risk Factors Model for Urinary Tract Infections

A risk factor model for urinary tract infections in patients with adult neurogenic lower urinary tract dysfunction performing clean intermittent catheterisation was developed; it consists of four domains, namely, (1) general (systemic) conditions in the patient, (2) individual urinary tract conditions in the patient, (3) routine aspects related to the patient, and (4) factors related to intermittent catheters per se. The conceptual model primarily concerns patients with spinal cord injury, spina bifida, multiple sclerosis, or cauda equina where intermittent catheterisation is a normal part of the bladder management. On basis of several literature searches and author consensus in case of lacking evidence, the model intends to provide an overview of the risk factors involved in urinary tract infections, with specific emphasis to describe those that in daily practice can be handled and modified by the clinician and so come to the benefit of the individual catheter user in terms of fewer urinary tract infections.