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Fitzpatrick MA, Nwafo N. Urinary Tract Infection Diagnostic and Management Considerations in People with Spinal Cord Injury and Neurogenic Bladder. Infect Dis Clin North Am 2024; 38:381-393. [PMID: 38580574 DOI: 10.1016/j.idc.2024.03.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/07/2024]
Abstract
Urinary tract infections (UTIs) are common complications in people with neurogenic bladder. Prevention, diagnosis, and treatment are challenging for several reasons, including a high prevalence of asymptomatic bacteriuria and catheter use, frequent ambiguous nonlocalizing signs and symptoms, increased risk for complications and difficult-to-treat pathogens, and a lack of effective preventative methods. Current research aims to improve elicitation and evaluation of signs and symptoms, implement algorithms to avoid urine cultures in asymptomatic patients and use appropriate antibiotics for UTI, and identify novel effective prevention methods.
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Affiliation(s)
- Margaret A Fitzpatrick
- Department of Medicine, Section of Infectious Diseases, VA Eastern Colorado Healthcare System, Aurora, CO, USA; Department of Medicine, Division of Infectious Diseases, University of Colorado Anschutz Medical Center, Aurora, CO, USA.
| | - Nnamdi Nwafo
- Department of Medicine, Division of Infectious Diseases, University of Colorado Anschutz Medical Center, CU Research Complex II, 12700 East 19th Avenue. Mail Stop B168, Aurora, CO 80045, USA
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Groah SL, Tractenberg RE. Intravesical Lactobacillus rhamnosus GG versus Saline Bladder Wash: Protocol for a Randomized, Controlled, Comparative Effectiveness Clinical Trial. Top Spinal Cord Inj Rehabil 2022; 28:12-21. [PMID: 36457355 PMCID: PMC9678213 DOI: 10.46292/sci22-00005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Background Complicated urinary tract infection (cUTI) is pervasive and costly among people with spinal cord injury (SCI) and neurogenic lower urinary tract dysfunction (NLUTD). Objectives To describe the protocol for a comparative effectiveness randomized controlled trial of intravesical Lactobacillus rhamnosus GG (LGG) versus saline bladder wash (BW) for self-management of urinary symptoms. Methods Comparative effectiveness trial of self-administered LGG versus saline bladder wash among 120 participants with SCI+NLUTD at least 6 months post SCI. The study has both treatment and prophylaxis phases. After predictive enrichment at screening, randomized participants will enter the treatment phase (6 months) in which they instill either LGG or normal saline after trigger symptoms occur (more cloudy or more foul-smelling urine). In the prophylaxis phase (6 months), participants will instill their respective intervention every 3 days after the first occurrence of trigger symptoms. Results Study results will provide a comparison of effects on Urinary Symptom Questionnaire for Neurogenic Bladder (USQNB) bladder and urine symptoms and episodes of "presumed UTIs"; number of days antibiotics were used (both self-reported); days of work, school, rehabilitation, or other activity lost due to urinary symptoms; engagement with the health care system; number of instillations; satisfaction; and safety. Conclusion cUTI is a variable clinical entity. Unlike clinical trials that assume a single, simple entity (UTI) in inclusion or outcome criteria, this protocol targets the mechanisms underlying cUTI causes and phenotypes. Featuring reliable and valid outcome measures with analytic methods specifically appropriate for quantifying self-report, patient self-management, inclusion of both intervention and prophylactic phases, and predictive enrichment, these design elements may be adopted for future research.
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Affiliation(s)
- Suzanne L. Groah
- MedStar National Rehabilitation Hospital, Washington, DC
- MedStar Georgetown University Hospital, Washington, DC
| | - Rochelle E. Tractenberg
- Collaborative for Research on Outcomes and Metrics, and Departments of Neurology, Biostatistics, Bioinformatics & Biomathematics, and Rehabilitation Medicine, Georgetown University, Washington, DC
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Šámal V, Paldus V, Fáčková D, Mečl J, Šrám J. The prevalence of antibiotic-resistant and multidrug-resistant bacteria in urine cultures from inpatients with spinal cord injuries and disorders: an 8-year, single-center study. BMC Infect Dis 2022; 22:239. [PMID: 35264096 PMCID: PMC8908566 DOI: 10.1186/s12879-022-07235-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Accepted: 03/02/2022] [Indexed: 11/13/2022] Open
Abstract
Background Patients, especially inpatients, with spinal cord lesions and disorders (SCI/D) have an elevated risk of recurrent urinary tract infections with multidrug resistant (MDR) bacteria. This study evaluated antimicrobial resistance and the prevalence of multidrug resistance and determined the risk factors for multidrug resistance. Methods In this retrospective cohort study, urine culture results were used to calculate the antimicrobial resistance rate and the incidence of infection with MDR bacteria in the SCI/D population. MDR was defined as acquired nonsusceptibility to at least one agent from three or more antimicrobial categories. The cohort included 402 inpatients from 2013 to 2020, with 1385 urine isolates. We included only the first isolate; duplicate isolates, defined as positive cultures of the same strain within 14 days, were excluded from the evaluation. Results The most common MDR strains were Klebsiella spp. (29%) and Escherichia coli (24%). MDR isolates were detected in 50% of the samples and extended spectrum beta-lactamase (ESBL)-producing isolates were detected in 26%, while carbapenem resistance was found in 0.1%. Significantly higher rates of infection with MDR bacteria were identified in groups of patients with indwelling urethral/suprapubic catheters (p = 0.003) and severity scores of C1–C4/AIS A–C (p = 0.01). We identified age (OR: 0.99, 95% CI; 0.98–0.99, p = 0.000), sex (OR: 1.55, 95% CI; 1.16–2.06, p = 0.003), management with urethral/suprapubic catheters (OR: 2.76, 95% CI; 2.04–3.74, p = 0.000), and spontaneous voiding (OR: 1.84, 95% CI; 1.03–3.29, p = 0.038) as independent predictors of multidrug resistance in our study population. Conclusions We identified a high antibiotic resistance rate and an increasing prevalence of infection with MDR bacteria in the SCI/D inpatient population. Particular attention should be given to bladder management, with an emphasis on minimizing the use of indwelling catheters.
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Affiliation(s)
- Vladimír Šámal
- Department of Urology, Krajská Nemocnice Liberec, Husova 10, 46063, Liberec, Czech Republic.
| | - Vít Paldus
- Department of Urology, Krajská Nemocnice Liberec, Husova 10, 46063, Liberec, Czech Republic
| | - Daniela Fáčková
- Department of Microbiology, Krajská Nemocnice Liberec, Liberec, Czech Republic
| | - Jan Mečl
- Department of Urology, Krajská Nemocnice Liberec, Husova 10, 46063, Liberec, Czech Republic
| | - Jaroslav Šrám
- Traumatology and Orthopedics Center, Krajská Nemocnice Liberec, Liberec, Czech Republic
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Multidrug-resistant bacteria in urine culture among patients with spinal cord injury and disorder: Time to first detection and analysis of risk factors. Spinal Cord 2022; 60:733-738. [PMID: 35197573 DOI: 10.1038/s41393-022-00774-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Revised: 02/06/2022] [Accepted: 02/08/2022] [Indexed: 11/08/2022]
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVES The aim of this study was to assess the time to first detection of multidrug-resistant bacteria (MDRB) in urine culture and identify risk factors associated with the first detection of MDRB (1st MDRB). SETTING Spinal Care Ward and Department of Microbiology, Regional Hospital Liberec a.s., Liberec, Czech Republic. METHOD We cultured urine samples from patients in the acute phase of spinal cord injury or disorder (SCI/D). Multidrug resistance (MDR) was defined as acquired nonsusceptibility to at least one agent from three or more antimicrobial categories. Multivariate logistic regression was used to assess the association of bladder management, broad-spectrum antibiotic exposure, mechanical ventilation, pressure ulcers, positive urine culture on admission, and other risk factors with 1st MDRB. We used only the first urine culture with MDRB for evaluation. RESULTS A total of 655 urine cultures from 246 individuals were evaluated, and 829 isolates were obtained. The MDRB prevalence among all isolates was 40.2%. MDRB was detected in 146 (59.3%) patients for the first time, and 76.0% of these isolates were from patients with asymptomatic bacteriuria. The median time to 1st MDRB was 37 days (95% CI, 33-41). According to multivariate logistic regression, 1st MDRB was associated with bladder management with urethral or suprapubic catheterization (OR: 2.8, 95% CI, 1.1-7.2). CONCLUSION The prevalence of infections caused by MDRB was high among the SCI/D population, with three-quarters from patients with asymptomatic bacteriuria. Bladder management with an indwelling catheter is associated with an increased risk of 1st MDRB.
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DeVivo MJ, Chen Y, Wen H. Cause of Death Trends Among Persons With Spinal Cord Injury in the United States: 1960-2017. Arch Phys Med Rehabil 2021; 103:634-641. [PMID: 34800477 DOI: 10.1016/j.apmr.2021.09.019] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Revised: 08/30/2021] [Accepted: 09/02/2021] [Indexed: 01/15/2023]
Abstract
OBJECTIVE To identify trends in causes of death after spinal cord injury (SCI) that could enhance understanding of why life expectancy after SCI has not improved in the last 3 decades. DESIGN Cohort study. SETTING Twenty-nine SCI Model Systems and 3 Shriners Hospitals. PARTICIPANTS Individuals with traumatic SCI (N=49,266) enrolled in the SCI Collaborative Survival Study Database between 1973 and 2017. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Age-standardized cause-specific SCI mortality rates and 95% confidence intervals were calculated for 5 time intervals (1960-1979, 1980-1989, 1990-1999, 2000-2009, and 2010-2017). RESULTS A total of 17,249 deaths occurred in 797,226 person-years of follow-up. Since 2010, the highest mortality rate was for respiratory diseases, followed by heart disease, cancer, infective and parasitic diseases (primarily septicemia), and unintentional injuries. Mortality rates for respiratory diseases, cancer, stroke, urinary diseases, and digestive diseases, initially decreased significantly but remained relatively stable since 1980, whereas essentially no progress occurred for infective and parasitic diseases. Mortality rates for heart disease, pulmonary embolus, and suicide decreased significantly throughout the entire study period, but were offset by increases in mortality rates for endocrine (primarily diabetes), nutritional, and metabolic diseases, as well as unintentional injuries. From 2010 to 2017, the overall age-standardized mortality rate was 3 times higher for individuals with SCI than the general population, ranging from 27% higher for cancer to 9 times higher for infective and parasitic diseases. CONCLUSION Improving life expectancy after SCI will require: (1) reducing mortality rates from respiratory diseases and septicemia that have remained high, (2) reversing current trends in diabetes and unintentional injury deaths, and (3) continuing to reduce mortality from heart disease and other leading causes.
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Affiliation(s)
- Michael J DeVivo
- Department of Physical Medicine and Rehabilitation, University of Alabama at Birmingham, Birmingham, AL
| | - Yuying Chen
- Department of Physical Medicine and Rehabilitation, University of Alabama at Birmingham, Birmingham, AL.
| | - Huacong Wen
- Department of Physical Medicine and Rehabilitation, University of Alabama at Birmingham, Birmingham, AL
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Iqbal M, Mittal G, Aggarwal M, Chaddha R. Clinico-microbiological profile of urinary tract infections in hospitalized spinal cord injury patients. JOURNAL OF ORTHOPAEDICS AND SPINE 2021. [DOI: 10.4103/joasp.joasp_50_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Toh SL, Lee BB, Simpson JM, Rice SA, Kotsiou G, Marial O, Ryan S. Effect of probiotics on multi-resistant organism colonisation in persons with spinal cord injury: secondary outcome of ProSCIUTTU, a randomised placebo-controlled trial. Spinal Cord 2020; 58:755-767. [PMID: 31953482 DOI: 10.1038/s41393-020-0420-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Revised: 01/03/2020] [Accepted: 01/09/2020] [Indexed: 12/25/2022]
Abstract
STUDY DESIGN Randomised double-blind placebo-controlled trial. OBJECTIVES Multi-resistant organism (MRO) colonisation is common in people with SCI. We aimed to determine whether Lactobacillus reuteri RC-14 + Lactobacillus GR-1 (RC14-GR1) and/or Lactobacillus rhamnosus GG + Bifidobacterium BB-12 (LGG-BB12) are effective in preventing or clearing MRO colonisation. SETTING New South Wales, Australia. METHODS The 207 SCI participants were randomised to one of four arms: (i) RC14-GR1 + LGG-BB12, (ii) RC14-GR1 + placebo, (iii) LGG-BB12 + placebo or (iv) double placebos for 6 months. Microbiological samples of nose, groin, urine and bowel were taken at baseline, 3 and 6 months. Analysis was conducted for the presence of methicillin-resistant Staphylococcus aureus (MRSA), multi-resistant gram-negative organisms (MRGNs) and vancomycin-resistant enterococcus (VRE). The outcomes were clearance of, or new colonisation with MRSA, MRGN, VRE or MROs and whether participants remained free of MRSA, MRGN, VRE or MROs throughout the study. Risk factors associated with an outcome were adjusted for using nominal or binary logistic regression. RESULTS There was a significant reduction in new MRGN colonisation compared with placebo for participants treated with RC14-GR1 (OR 0.10, 95% CI, 0.01-0.88, P = 0.04), after allowing that inpatients were more likely to be newly colonised (OR 21.41, 95% CI, 3.98-115.13, P < 0.0001). Participants who intermittent self-catheterised (IMC) were more likely to remain MRO-free than those utilising SPC or IDCs (OR 2.80, 95% CI, 1.41-5.54, P = 0.009). CONCLUSIONS Probiotics are ineffective at clearing MROs in people with SCI. However, RC14-GR1 is effective at preventing new colonisation with MRGNs. The use of IMC significantly improves the chance of remaining MRO-free.
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Affiliation(s)
- Swee-Ling Toh
- Department of Spinal and Rehabilitation Medicine, Prince of Wales Hospital, Sydney, NSW, Australia. .,Sydney School of Public Health, University of Sydney, Sydney, NSW, Australia.
| | - Bonsan Bonne Lee
- Department of Spinal and Rehabilitation Medicine, Prince of Wales Hospital, Sydney, NSW, Australia.,Neuroscience Research Australia (NeuRA) and UNSW Sydney, Sydney, NSW, Australia
| | - Judy M Simpson
- Sydney School of Public Health, University of Sydney, Sydney, NSW, Australia
| | - Scott A Rice
- Singapore Centre for Environmental Life Sciences Engineering and the School of Biological Sciences, Nanyang Technological University, Nanyang, Singapore.,The ithree Institute, University of Technology Sydney, Sydney, NSW, Australia
| | - George Kotsiou
- Department of Infectious Diseases and Microbiology, NSW Health Pathology, Royal North Shore Hospital, Sydney, NSW, Australia
| | - Obaydullah Marial
- Neuroscience Research Australia (NeuRA) and UNSW Sydney, Sydney, NSW, Australia
| | - Suzanne Ryan
- Neuroscience Research Australia (NeuRA) and UNSW Sydney, Sydney, NSW, Australia
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Craven BC, Alavinia SM, Gajewski JB, Parmar R, Disher S, Ethans K, Shepherd J, Omidvar M, Farahani F, Hassouna M, Welk B. Conception and development of Urinary Tract Infection indicators to advance the quality of spinal cord injury rehabilitation: SCI-High Project. J Spinal Cord Med 2019; 42:205-214. [PMID: 31573440 PMCID: PMC6781249 DOI: 10.1080/10790268.2019.1647928] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Context: Urinary tract infections (UTI) are the most frequent secondary health condition following spinal cord injury or disease (SCI/D) that adversely impact overall health and quality of life, and often result in rehabilitation service interruptions, emergency department visits, and urinary sepsis. Methods: Experts in Urohealth and/or UTI recognition and management and the SCI-High Project Team used a combination of evidence synthesis and consensus methods for developing the UTI indicators. A systematic search and a Driver diagram analysis were applied to identify key factors influencing UTI. This Driver diagram guided the UTI Working Group when defining the construct, specifying the aim for the UTI SCI/D quality indicators, and developing the UTI diagnostic checklist and fever definition. Results: The structure indicator was the proportion of patients with a health care professional (i.e. family physician or urologist) able to follow-up with the patient regarding urine culture and sensitivity results within 48-72 h of collection. The Working Group knowingly adopted a single checklist for UTI diagnosis, recognizing the stark contrast in the complexity of diagnosis in acute versus community settings. The process indicator is the proportion of SCI/D rehabilitation inpatients with UTI as defined by the UTI diagnostic checklist. The outcome indicator is the proportion of SCI/D rehabilitation inpatients with inappropriate antibiotic prescription. Conclusion: UTI can be diagnosed using the developed symptoms and signs checklist. These structure, process, and outcome quality indicators will ultimately reduce inappropriate antibiotic therapy for UTI and the rising incidence of antibiotic resistance among community-dwelling individuals with chronic SCI/D.
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Affiliation(s)
- B. Catharine Craven
- KITE, Toronto Rehab – University Health Network, Toronto, Ontario, Canada,Division of Physical Medicine and Rehabilitation, Department of Medicine, University of Toronto, Toronto, Ontario, Canada,Brain and Spinal Cord Rehabilitation Program, Toronto Rehabilitation Institute – University Health Network, Toronto, Ontario, Canada,Correspondence to: B. Catharine Craven, KITE – Toronto Rehab – University Health Network, 206-H 520 Sutherland Drive, Toronto, Ontario M4G3V9, Canada; Ph: 416-597-3422 x6122.
| | - S. Mohammad Alavinia
- KITE, Toronto Rehab – University Health Network, Toronto, Ontario, Canada,Division of Physical Medicine and Rehabilitation, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | | | - Raj Parmar
- Spinal Cord Injury Rehabilitation Clinic, Foothills Medical Centre, Calgary, Canada
| | - Sandi Disher
- Brain and Spinal Cord Rehabilitation Program, Toronto Rehabilitation Institute – University Health Network, Toronto, Ontario, Canada
| | - Karen Ethans
- Division of Physical Medicine and Rehabilitation, Department of Medicine, University of Manitoba, Winnipeg, Canada
| | - John Shepherd
- KITE, Toronto Rehab – University Health Network, Toronto, Ontario, Canada,Faculty of Medicine, Rehabilitation Sciences Institute, University of Toronto, Toronto, Ontario, Canada
| | - Maryam Omidvar
- KITE, Toronto Rehab – University Health Network, Toronto, Ontario, Canada
| | - Farnoosh Farahani
- KITE, Toronto Rehab – University Health Network, Toronto, Ontario, Canada
| | - Magdy Hassouna
- Department of Surgery, Division of Urology, University of Toronto, Toronto, Ontario, Canada,Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| | - Blayne Welk
- Department of Surgery (Urology), Schulich School of Medicine & Dentistry, Western University, London, Canada
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Probiotics [LGG-BB12 or RC14-GR1] versus placebo as prophylaxis for urinary tract infection in persons with spinal cord injury [ProSCIUTTU]: a randomised controlled trial. Spinal Cord 2019; 57:550-561. [PMID: 30814670 PMCID: PMC6760555 DOI: 10.1038/s41393-019-0251-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2018] [Revised: 01/14/2019] [Accepted: 01/14/2019] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Randomised double-blind factorial-design placebo-controlled trial. OBJECTIVE Urinary tract infections (UTIs) are common in people with spinal cord injury (SCI). UTIs are increasingly difficult to treat due to emergence of multi-resistant organisms. Probiotics are efficacious in preventing UTIs in post-menopausal women. We aimed to determine whether probiotic therapy with Lactobacillus reuteri RC-14+Lactobacillus GR-1 (RC14-GR1) and/or Lactobacillus rhamnosus GG+Bifidobacterium BB-12 (LGG-BB12) are effective in preventing UTI in people with SCI. SETTING Spinal units in New South Wales, Australia with their rural affiliations. METHODS We recruited 207 eligible participants with SCI and stable neurogenic bladder management. They were randomised to one of four arms: RC14-GR1+LGG-BB12, RC14-GR1+placebo, LGG-BB12+ placebo or double placebos for 6 months. Randomisation was stratified by bladder management type and inpatient or outpatient status. The primary outcome was time to occurrence of symptomatic UTI. RESULTS Analysis was based on intention to treat. Participants randomised to RC14-GR1 had a similar risk of UTI as those not on RC14-GR1 (HR 0.67; 95% CI: 0.39-1.18; P = 0.17) after allowing for pre-specified covariates. Participants randomised to LGG-BB12 also had a similar risk of UTI as those not on LGG-BB12 (HR 1.29; 95% CI: 0.74-2.25; P = 0.37). Multivariable post hoc survival analysis for RC14-GR1 only vs. the other three groups showed a potential protective effect (HR 0.46; 95% CI: 0.21-0.99; P = 0.03), but this result would need to be confirmed before clinical application. CONCLUSION In this RCT, there was no effect of RC14-GR1 or LGG-BB12 in preventing UTI in people with SCI.
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Management of established pressure ulcer infections in spinal cord injury patients. Med Mal Infect 2019; 49:9-16. [DOI: 10.1016/j.medmal.2018.05.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2017] [Revised: 08/31/2017] [Accepted: 05/29/2018] [Indexed: 12/20/2022]
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Fitzpatrick MA, Suda KJ, Safdar N, Burns SP, Jones MM, Poggensee L, Ramanathan S, Evans CT. Changes in bacterial epidemiology and antibiotic resistance among veterans with spinal cord injury/disorder over the past 9 years. J Spinal Cord Med 2018; 41:199-207. [PMID: 28198662 PMCID: PMC5901456 DOI: 10.1080/10790268.2017.1281373] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
Abstract
OBJECTIVE Patients with spinal cord injury and disorder (SCI/D) have an increased risk of infection with multidrug-resistant (MDR) bacteria. We described bacterial epidemiology and resistance in patients with SCI/D at Veterans Affairs Medical Centers (VAMCs) for the past 9 years. DESIGN Retrospective cohort. SETTING One hundred thirty VAMCs. PARTICIPANTS Veterans with SCI/D and bacterial cultures with antibiotic susceptibility testing performed between 1/1/2005-12/31/2013. Single cultures with contaminants and duplicate isolates within 30 days of initial isolates were excluded. INTERVENTIONS None. OUTCOMES Trends in microbial epidemiology and antibiotic resistance. RESULTS Included were 216,504 isolates from 19,421 patients. Urine was the most common source and Gram-negative bacteria (GNB) were isolated most often, with 36.1% of GNB being MDR. Logistic regression models clustered by patient and adjusted for location at an SCI/D center and geographic region showed increased odds over time of vancomycin resistance in Enterococcus [adjusted odds ratio (aOR) 1.67, 95% confidence interval (CI) 1.30-2.15], while methicillin resistance in Staphylococcus aureus remained unchanged (aOR 0.90, 95% CI 0.74-1.09). There were also increased odds of fluoroquinolone resistance (aOR 1.39, 95% CI 1.31-1.47) and multidrug resistance (aOR 1.46, 95% CI 1.38-1.55) in GNB, with variability in the odds of MDR bacteria by geographic region. CONCLUSIONS GNB are isolated frequently in Veterans with SCI/D and have demonstrated increasing resistance over the past 9 years. Priority should be given to controlling the spread of resistant bacteria in this population. Knowledge of local and regional epidemiologic trends in antibiotic resistance in patients with SCI/D may improve appropriate antibiotic prescribing.
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Affiliation(s)
- Margaret A. Fitzpatrick
- Department of Veterans Affairs, Center of Innovation for Complex Chronic Healthcare, Edward Hines, Jr. VA Hospital, Hines, Illinois, USA,Department of Medicine, Division of Infectious Diseases, Loyola University Stritch School of Medicine, Maywood, Illinois, USA,Correspondence to: Margaret A. Fitzpatrick, MD, MS, 5000 S. 5th Ave., Hines, IL 60141, USA.
| | - Katie J. Suda
- Department of Veterans Affairs, Center of Innovation for Complex Chronic Healthcare, Edward Hines, Jr. VA Hospital, Hines, Illinois, USA,Department of Pharmacy Systems, Outcomes and Policy, College of Pharmacy, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Nasia Safdar
- Department of Veterans Affairs, William S. Middleton VA Medical Center, Madison, Wisconsin, USA,Department of Medicine, Division of Infectious Diseases, University of Wisconsin, Madison, Wisconsin, USA
| | - Stephen P. Burns
- Department of Veterans Affairs, VA Puget Sound Healthcare System, Seattle, Washington, USA,Department of Rehabilitation Medicine, University of Washington, Seattle, Washington, USA
| | - Makoto M. Jones
- Department of Veterans Affairs, VA Salt Lake City Healthcare System, Salt Lake City, Utah, USA,Department of Medicine, Division of Epidemiology, University of Utah, Salt Lake City, Utah, USA
| | - Linda Poggensee
- Department of Veterans Affairs, Center of Innovation for Complex Chronic Healthcare, Edward Hines, Jr. VA Hospital, Hines, Illinois, USA
| | - Swetha Ramanathan
- Department of Veterans Affairs, Center of Innovation for Complex Chronic Healthcare, Edward Hines, Jr. VA Hospital, Hines, Illinois, USA
| | - Charlesnika T. Evans
- Department of Veterans Affairs, Center of Innovation for Complex Chronic Healthcare, Edward Hines, Jr. VA Hospital, Hines, Illinois, USA,Center for Healthcare Studies and Department of Preventive Medicine Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
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12
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Prevalence and Factors Associated With Multidrug-Resistant Gram-Negative Organisms in Patients With Spinal Cord Injury. Infect Control Hosp Epidemiol 2017; 38:1464-1471. [DOI: 10.1017/ice.2017.238] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVEInfections caused by multidrug-resistant gram-negative organisms (MDRGNOs) have been increasing every year. The objective of this study was to describe the prevalence of MDRGNOs and factors associated with MDRGNOs in patients with spinal cord injury or disorder (SCI/D).DESIGNRetrospective cohort study.METHODSDepartment of Veterans Affairs (VA) electronic health record data from 142 VA facilities were evaluated for 19,642 patients with SCI/D. Multivariable cluster-adjusted models were fit to identify factors associated with MDRGNO.RESULTSGram-negative (GN) cultures occurred in 44% of patients with SCI/D receiving care at VA facilities, and 11,527 (41.3%) GN cultures had an MDRGNO. The most frequent GN organisms (GNOs) were Escherichia coli (28.5%), Klebsiella pneumoniae (17.0%), and Pseudomonas aeruginosa (16.0%). Two-thirds of GN cultures were from the outpatient setting, where MDRGNO prevalence was 37.6%. Significant geographic variation in the prevalence of MDRGNOs was identified (South, 44.7%; Northeast, 44.3%; West, 36.8%; Midwest, 34.4%). Other factors associated with an MDRGNO were older age, injury characteristics, comorbidities, specimen type, healthcare setting, and healthcare exposure. Black (odds ratio [OR], 1.58; 95% confidence interval [CI], 1.39–1.78) and Hispanic race (OR, 1.58; 95% CI, 1.28–1.95), polymicrobial culture (OR, 2.67; 95% CI, 2.46–2.90), and antibiotic use in the previous 90 days (OR, 1.62; 95% CI, 1.50–1.76) were also associated with having an MDRGNO.CONCLUSIONSMDRGNOs were common in community and healthcare settings among veterans with SCI/D, with significant geographic variation. Health care and antibiotic exposures were significant factors associated with MDRGNOs. Priority should be given to controlling the spread of MDRGNOs in this special population, including a focus on judicious use of antibiotics.Infect Control Hosp Epidemiol 2017;38:1464–1471
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Cox L, He C, Bevins J, Clemens JQ, Stoffel JT, Cameron AP. Gentamicin bladder instillations decrease symptomatic urinary tract infections in neurogenic bladder patients on intermittent catheterization. Can Urol Assoc J 2017; 11:E350-E354. [PMID: 29382457 DOI: 10.5489/cuaj.4434] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
INTRODUCTION This study aimed to determine if gentamicin bladder instillations reduce the rate of symptomatic urinary tract infection (UTI) in neurogenic bladder (NGB) patients on intermittent self-catheterization (ISC) who have recurrent UTIs. Secondary aims were to examine the effects of intravesical gentamicin on the organism resistance patterns. METHODS We retrospectively reviewed our prospective NGB database. Inclusion criteria were NGB patients performing ISC exclusively for bladder drainage with clinical data available for six months before and six months after initiating prophylactic intravesical gentamicin instillations. Symptomatic UTIs were defined as symptoms consistent with UTI plus the need for antibiotic treatment. RESULTS Twenty-two patients met inclusion criteria; etiology of NGB was 63.6% spinal cord injury, 13.6% multiple sclerosis. Median time since injury/diagnosis was 14 years and 6/22 (27.3%) had undergone urological reconstruction. Patients had fewer symptomatic UTI's (median 4 vs. 1 episodes; p<0.004) and underwent fewer courses of oral antibiotics after initiating gentamicin (median 3.5 vs. 1; p<0.01). Days of oral antibiotic therapy decreased from 15 before to five after gentamicin, but this did not reach significance. There were fewer telephone encounters for UTI concerns per patient (median 3 vs. 0; p=0.03). The proportion of multi-drug-resistant organisms in urine cultures decreased from 58.3% to 47.1% (p=0.04) and the rate of gentamicin resistance did not increase. Adverse events were mild and rare. CONCLUSIONS Gentamicin bladder instillations decrease symptomatic UTI episodes and reduce oral antibiotics in patients with NGB on ISC who were suffering from recurrent UTIs. Antibiotic resistance decreased while on gentamicin instillations.
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Affiliation(s)
- Lindsey Cox
- Department of Urology; University of Michigan, Ann Arbor, MI, United States
| | - Chang He
- Department of Urology; University of Michigan, Ann Arbor, MI, United States
| | - Jack Bevins
- College of Medicine; University of Michigan, Ann Arbor, MI, United States
| | - J Quentin Clemens
- Department of Urology; University of Michigan, Ann Arbor, MI, United States
| | - John T Stoffel
- Department of Urology; University of Michigan, Ann Arbor, MI, United States
| | - Anne P Cameron
- Department of Urology; University of Michigan, Ann Arbor, MI, United States
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Toh S, Boswell‐Ruys CL, Lee BSB, Simpson JM, Clezy KR. Probiotics for preventing urinary tract infection in people with neuropathic bladder. Cochrane Database Syst Rev 2017; 9:CD010723. [PMID: 28884476 PMCID: PMC6483743 DOI: 10.1002/14651858.cd010723.pub2] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
BACKGROUND Neuropathic or neurogenic bladder describes a process of dysfunctional voiding as the result of injury in the brain, spinal cord or nerves innervating the bladder. People with neuropathic bladder, such as from spinal cord injury (SCI), are at significant risk of morbidity from urinary tract infections (UTI). Effective methods to prevent UTI in people with SCI have been sought for many years. Probiotics (micro-organisms that exert beneficial health effects in the host) have been recommended for bacterial interference of the urological tract to reduce colonisation by uropathogen and to manage the dual problems of infection and antibiotic resistance. OBJECTIVES This review looked at the benefits and harms of probiotics in preventing symptomatic UTI in people with neuropathic bladder compared with placebo, no therapy, or non-antibiotic prophylaxis (cranberry juice, methenamine hippurate, topical oestrogen). SEARCH METHODS We searched the Cochrane Kidney and Transplant Specialised Register up to 10 March 2017 through contact with the Information Specialist using search terms relevant to this review. Studies in the Specialised Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal, and ClinicalTrials.gov. SELECTION CRITERIA All randomised controlled trials (RCTs), quasi-RCTs and cross-over RCTs looking at the use of probiotics for the prophylaxis of UTI in people with neuropathic bladders was considered for inclusion. Men, women and children of all ages with neuropathic bladders from neurological injury such as suprapontine, supra sacral and sacral aetiologies was included. All bladder management types, including reflex voiding, time voiding, indwelling and intermittent catheterization were eligible for this review.Studies comparing probiotics to placebo, no treatment or other non-antibiotic prophylaxis was included. Studies comparing probiotics with antibiotics or in combination with antibiotics were excluded. DATA COLLECTION AND ANALYSIS Summary estimates of effect were obtained using a random-effects model, and results were expressed as risk ratios (RR) and their 95% confidence intervals (CI) for dichotomous outcomes, and mean difference (MD) or standardised mean difference (SMD) and 95% CI were planned for continuous outcomes. MAIN RESULTS This review includes a total of three studies (one cross-over and two parallel RCTs) which involved 110 participants. All three studies looked at intravesical instillation of a low virulent Escherichia coli (E. coli) strain in reducing the risk of symptomatic UTI in participants with neuropathic bladder, predominantly from SCI. Two studies used the E. coli 83972 strain and one study used the E. coli HU2117 strain.We did not find any RCTs involving other probiotics or other routes of administration for preventing UTI in people with neuropathic bladder.There was consistency in definition of symptomatic UTI in all three studies. Symptoms that all studies considered were relevant to diagnose UTI were adequately defined. All three studies defined microbiological diagnosis of symptomatic UTI.Asymptomatic bacteriuria was not considered an outcome measure in any of the included studies; however it was defined in two studies to establish successful inoculation.It is uncertain if the risk of symptomatic UTI is reduced with bladder inoculation using E. coli because the certainty of the evidence is very low (3 studies, 110 participants: RR 0.32, 95% CI 0.08 to 1.19; I2 = 82%).Two studies reported adverse events. One study reported one episode of autonomic dysreflexia. One study reported three symptomatic UTI occurring in two patients, and two studies mentioned the absence of septicaemia and pyelonephritis. Intravesical instillation was reported as "generally safe". One study reported high attrition rates in participants due to the need to adhere to strict instillation protocols.The overall quality of the studies was poor. All three studies had high risk of attrition bias due to failure of an intention-to-treat analysis which undermines the randomisation process and weakened the results of the studies. All three studies also had high risk of reporting bias. AUTHORS' CONCLUSIONS In this review, there were no studies identified addressing oral probiotics in preventing UTI in people with neuropathic bladder. It is uncertain if the risk of symptomatic UTI is reduced in people with neuropathic bladders via intravesical instillation of non-pathogenic E. coli as data were derived from small studies with high risk of bias.Although very minimal levels of harm was reported with this procedure, due to variable success rates, the need for strict adherence to instillation protocols together with high attrition rates in these studies, it is doubtful bladder instillation will be a widely accepted intervention in its current form.It is recommended that further appropriately powered RCTs with more robust methodological reporting be carried out.
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Affiliation(s)
- Swee‐Ling Toh
- Prince of Wales HospitalSpinal Medicine DepartmentLevel 2, High Street EntranceRandwickNSWAustralia2031
| | | | - Bon San B Lee
- Prince of Wales HospitalSpinal Medicine DepartmentLevel 2, High Street EntranceRandwickNSWAustralia2031
| | - Judy M Simpson
- The University of SydneySydney School of Public HealthEdward Ford Building, A27SydneyNSWAustralia2006
| | - Kate R Clezy
- Prince of Wales HospitalInfectious DiseasesBarker StreetRandwickNSWAustralia2031
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Klebsiella pneumoniae carbapenemase-producing K. pneumoniae (KPC-KP) in brain and spinal cord injury patients: potential for prolonged colonization. Spinal Cord 2016; 55:390-395. [PMID: 27752059 DOI: 10.1038/sc.2016.136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2016] [Revised: 08/19/2016] [Accepted: 08/22/2016] [Indexed: 11/09/2022]
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVES To determine the prevalence of brain and spinal cord injury (BSCI) patients among all patients with Klebsiella pneumoniae carbapenemase-producing K. pneumoniae (KPC-KP) and to evaluate clinical characteristics and duration of colonization. SETTING Tertiary care academic medical center. METHODS Electronic medical records of BSCI patients with KPC-KP from February 2009 to December 2014 were reviewed to determine clinical characteristics. Patients with multiple KPC-KPs were defined as those with isolates in different calendar months, and patients with a single positive isolate were compared with those with repeatedly positive isolates. Variables with a P-value of ⩽0.05 were considered statistically significant. Two archived isolates recovered from separate cultures of the same patient were compared with pulsed-field gel electrophoresis to calculate the duration of colonization. RESULTS Of the 218 patients with KPC-KP, 86 (39%) had BSCI and 27 (31%) had multiple KPC-KPs. The KPC-KPs from 20 (74%) patients with multiple isolates were available for analysis. Patients with repeated positive isolates were more likely to be younger (P=0.05), African American (P=0.05), suffer gunshot injuries (P=0.01) and other trauma (P=0.03) and have decubitus ulcers (P=0.05). Of the 20 patients with multiple isolates for analysis, 13 (65%) patients were colonized with the same strain type over time, and the strain persisted on average 373 days. CONCLUSION BSCI patients comprise a significant percentage of our KPC-KP population. Owing to repeated hospitalizations and prolonged colonization, they represent a substantial reservoir for these multidrug-resistant pathogens.
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Poirier C, Dinh A, Salomon J, Grall N, Andremont A, Bernard L. Prevention of urinary tract infections by antibiotic cycling in spinal cord injury patients and low emergence of multidrug resistant bacteria. Med Mal Infect 2016; 46:294-9. [DOI: 10.1016/j.medmal.2016.02.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2015] [Revised: 12/15/2015] [Accepted: 02/25/2016] [Indexed: 10/21/2022]
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Lee BB, Toh SL, Ryan S, Simpson JM, Clezy K, Bossa L, Rice SA, Marial O, Weber G, Kaur J, Boswell-Ruys C, Goodall S, Middleton J, Tudehope M, Kotsiou G. Probiotics [LGG-BB12 or RC14-GR1] versus placebo as prophylaxis for urinary tract infection in persons with spinal cord injury [ProSCIUTTU]: a study protocol for a randomised controlled trial. BMC Urol 2016; 16:18. [PMID: 27084704 PMCID: PMC4833921 DOI: 10.1186/s12894-016-0136-8] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2015] [Accepted: 03/28/2016] [Indexed: 01/20/2023] Open
Abstract
Background Urinary tract infections [UTIs] are very common in people with Spinal Cord Injury [SCI]. UTIs are increasingly difficult and expensive to treat as the organisms that cause them become more antibiotic resistant. Among the SCI population, there is a high rate of multi-resistant organism [MRO] colonisation. Non-antibiotic prevention strategies are needed to prevent UTI without increasing resistance. Probiotics have been reported to be beneficial in preventing UTIs in post-menopausal women in several in vivo and in vitro studies. The main aim of this study is to determine whether probiotic therapy with combinations of Lactobacillus reuteri RC-14 + Lactobacillus rhamnosus GR-1 [RC14-GR1] and/or Lactobacillus rhamnosus GG + Bifidobacterium BB-12 [LGG-BB12] are effective in preventing UTI in people with SCI compared to placebo. Method This is a multi-site randomised double-blind double-dummy placebo-controlled factorial design study conducted in New South Wales, Australia. All participants have a neurogenic bladder as a result of spinal injury. Recruitment started in April 2011. Participants are randomised to one of four arms, designed for factorial analysis of LGG-BB12 and/or RC14-GR1 v Placebo. This involves 24 weeks of daily oral treatment with RC14-GR1 + LGG-BB12, RC14-GR1 + placebo, LGG-BB12 + placebo or two placebo capsules. Randomisation is stratified by bladder management type and inpatient status. Participants are assessed at baseline, three months and six months for Short Form Health Survey [SF-36], microbiological swabs of rectum, nose and groin; urine culture and urinary catheters for subjects with indwelling catheters. A bowel questionnaire is administered at baseline and three months to assess effect of probiotics on bowel function. The primary outcome is time from randomisation to occurrence of symptomatic UTI. The secondary outcomes are change of MRO status and bowel function, quality of life and cost-effectiveness of probiotics in persons with SCI. The primary outcome will be analysed using survival analysis of factorial groups, with Cox regression modelling to test the effect of each treatment while allowing for the other, assuming no interaction effect. Hazard ratios and Kaplan-Meier survival curves will be used to summarise results. Discussion If these probiotics are shown to be effective in preventing UTI and MRO colonisation, they would be a very attractive alternative for UTI prophylaxis and for combating the increasing rate of antibiotic resistance after SCI. Trial registration Australian New Zealand Clinical Trials Registry [ACTRN 12610000512022]. Date of registration: 21 June 2010. Electronic supplementary material The online version of this article (doi:10.1186/s12894-016-0136-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Bonsan Bonne Lee
- Neuroscience Research Australia [NeuRA] and the University of New South Wales, Sydney, Australia.,Department of Spinal and Rehabilitation Medicine, Prince of Wales Hospital, Sydney, Australia
| | - Swee-Ling Toh
- Department of Spinal and Rehabilitation Medicine, Prince of Wales Hospital, Sydney, Australia. .,School of Public Health, University of Sydney, Sydney, Australia.
| | - Suzanne Ryan
- Neuroscience Research Australia [NeuRA] and the University of New South Wales, Sydney, Australia
| | - Judy M Simpson
- School of Public Health, University of Sydney, Sydney, Australia
| | - Kate Clezy
- Department of Infectious Diseases, Prince of Wales Hospital, Sydney, Australia
| | - Laetitia Bossa
- Neuroscience Research Australia [NeuRA] and the University of New South Wales, Sydney, Australia.,Centre for Marine Bio-Innovation, University of New South Wales, Sydney, Australia
| | - Scott A Rice
- Centre for Marine Bio-Innovation, University of New South Wales, Sydney, Australia.,The Singapore Centre for Life Sciences Engineering and the School of Biological Sciences, Nanyang Technological University, Singapore, Singapore
| | - Obaydullah Marial
- Department of Spinal and Rehabilitation Medicine, Prince of Wales Hospital, Sydney, Australia.,Royal Rehabilitation Centre Sydney, Sydney, Australia.,Royal North Shore Hospital, Sydney, Australia
| | - Gerard Weber
- Royal Rehabilitation Centre Sydney, Sydney, Australia
| | | | - Claire Boswell-Ruys
- Neuroscience Research Australia [NeuRA] and the University of New South Wales, Sydney, Australia
| | - Stephen Goodall
- Centre for Health Economics Research and Evaluation [CHERE], University of Technology Sydney, Sydney, Australia
| | - James Middleton
- John Walsh Centre for Rehabilitation Research, Kolling Institute, Northern Sydney Local Health District, St Leonards, NSW, 2065, Australia.,Sydney Medical School Northern, University of Sydney, Sydney, Australia
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Unique Risks and Clinical Outcomes Associated With Extended-Spectrum β-Lactamase Enterobacteriaceae in Veterans With Spinal Cord Injury or Disorder: A Case-Case-Control Study. Infect Control Hosp Epidemiol 2016; 37:768-76. [PMID: 27025908 DOI: 10.1017/ice.2016.60] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVES To describe the burden of extended-spectrum β-lactamase (ESBL) Enterobacteriaceae in veterans with spinal cord injury or disorder (SCI/D), to identify risk factors for ESBL acquisition, and to assess impact on clinical outcomes DESIGN Retrospective case-case-control study PATIENTS AND SETTING Veterans with SCI/D and utilization at a Veterans' Affairs medical center from January 1, 2012, to December 31, 2013. METHODS Patients with a positive culture for ESBL Klebsiella pneumoniae, Escherichia coli, or Proteus mirabilis were matched with patients with non-ESBL organisms by organism, facility, and level of care and to uninfected controls by facility and level of care. Inpatients were also matched by time at risk. Univariate and multivariate matched models were assessed for differences in risk factors and outcomes. RESULTS A total of 492 cases (62.6% outpatients) were matched 1:1 with each comparison group. Recent prior use of fluoroquinolones and prior use of third- and fourth-generation cephalosporins were independently associated with ESBL compared to the non-ESBL group (adjusted odds ratio [aOR], 2.61; 95% confidence interval [CI], 1.77-3.84; P<.001 for fluoroquinolones and aOR, 3.86; 95% CI, 2.06-7.25; P<.001 for third- and fourth-generation cephalosporins) and the control group (aOR, 2.10; 95% CI, 1.29-3.43; P = .003 for fluoroquinolones; and aOR, 3.31; 95% CI, 1.56-7.06; P=.002 for third- and fourth-generation cephalosporins). Although there were no differences in mortality rate, the ESBL group had a longer post-culture length of stay (LOS) than the non-ESBL group (incidence rate ratio, 1.36; 95% CI, 1.13-1.63; P=.001). CONCLUSIONS All SCI/D patients with ESBL were more likely to have had recent exposure to fluoroquinolones or third- and fourth-generation cephalosporins, and hospitalized patients were more likely to have increased post-culture LOS. Programs targeted toward reduced antibiotic use in SCI/D patients may prevent subsequent ESBL acquisition. Infect Control Hosp Epidemiol 2016;37:768-776.
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Bacterial susceptibility patterns in patients with spinal cord injury and disorder (SCI/D): an opportunity for customized stewardship tools. Spinal Cord 2016; 54:1001-1009. [DOI: 10.1038/sc.2016.38] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2015] [Revised: 02/08/2016] [Accepted: 02/13/2016] [Indexed: 11/08/2022]
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Blood stream infections due to multidrug-resistant organisms among spinal cord-injured patients, epidemiology over 16 years and associated risks: a comparative study. Spinal Cord 2016; 54:720-5. [PMID: 26882486 DOI: 10.1038/sc.2015.234] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2015] [Revised: 11/04/2015] [Accepted: 12/09/2015] [Indexed: 01/19/2023]
Abstract
STUDY DESIGN Retrospective study. OBJECTIVES We aimed to describe the epidemiology of multidrug-resistant organisms (MDROs) during bloodstream infection (BSI) and identify associated risks of MDROs among patients with spinal cord injury (SCI). SETTING A teaching hospital, expert center in disability, in France. METHODS We studied a retrospective cohort of all BSIs occurring in SCI patients hospitalized over 16 years. We described the prevalence of MDRO BSI among this population and its evolution over time and compared the BSI population due to MDROs and due to non-MDROs. RESULTS A total of 318 BSIs occurring among 256 patients were included in the analysis. The most frequent primary sites of infection were urinary tract infection (34.0%), pressure sore (25.2%) and catheter line-associated bloodstream infection (11.3%). MDROs were responsible for 41.8% of BSIs, and this prevalence was stable over 16 years. No significant associated factor for MDRO BSI could be identified concerning sociodemographic and clinical characteristics, primary site of infection and bacterial species in univariate and multivariate analyses. BSI involving MDROs was not associated with initial severity of sepsis compared with infection without MDROs (43.8 vs 43.6%, respectively) and was not associated either with 30th-day mortality (6.2 vs 9%, respectively). CONCLUSION During BSI occurrence in an SCI population, MDROs are frequent but remain stable over years. No associated risk can be identified that would help optimize antibiotic treatment. Neither the severity of the episode nor the mortality is significantly different when an MDRO is involved.
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Kang MS, Lee BS, Lee HJ, Hwang SW, Han ZA. Prevalence of and Risk Factors for Multidrug-Resistant Bacteria in Urine Cultures of Spinal Cord Injury Patients. Ann Rehabil Med 2015; 39:686-95. [PMID: 26605166 PMCID: PMC4654075 DOI: 10.5535/arm.2015.39.5.686] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2015] [Accepted: 05/11/2015] [Indexed: 11/24/2022] Open
Abstract
Objective To identify the prevalence of multidrug-resistant (MDR) bacteria and identify their specific risk factors in routine urine specimens of spinal cord injury (SCI) patients. Methods This study was designed in a retrospective manner, reviewing the medical records of SCI patients who were admitted to a specialized SCI unit between January 2001 and December 2013. Patients were investigated for age, gender, American Spinal Injury Association impairment scale, SCI level, duration after injury, bladder management method, and hospitalization history within four weeks prior to visiting our unit. The results of routine urine cultures including presence of MDR organisms were analyzed. Results Among the total 2,629 urine samples from the newly admitted SCI patients, significant bacteriuria was identified in 1,929 (73.4%), and MDR organisms were isolated in 29 (1.1%) cultures. There was an increasing trend of MDR organism prevalence from 2001 to 2013 (p<0.01). The isolation of MDR organisms in inpatients who were admitted for rehabilitation (1.3%) was significantly higher than it was among community-residing persons (0.2%) (p<0.05). By voiding method, patients who used a suprapubic indwelling catheter (3.3%) or a urethral indwelling catheter (2.6%) showed a higher rate of MDR organism isolation (p<0.05). Conclusion There was an increasing trend of MDR organism isolation in SCI patients. Inpatients and persons who used indwelling catheters showed a higher risk of MDR organism isolation.
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Affiliation(s)
- Min-Soo Kang
- Department of Physical Medicine and Rehabilitation, National Rehabilitation Center, Seoul, Korea
| | - Bum-Suk Lee
- Department of Physical Medicine and Rehabilitation, National Rehabilitation Center, Seoul, Korea
| | - Hye-Jin Lee
- Department of Physical Medicine and Rehabilitation, National Rehabilitation Center, Seoul, Korea
| | - Seung-Won Hwang
- Department of Physical Medicine and Rehabilitation, National Rehabilitation Center, Seoul, Korea
| | - Zee-A Han
- Department of Physical Medicine and Rehabilitation, National Rehabilitation Center, Seoul, Korea
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Fourcade C, Canini L, Lavigne JP, Sotto A. A comparison of monomicrobial versus polymicrobial Enterococcus faecalis bacteriuria in a French University Hospital. Eur J Clin Microbiol Infect Dis 2015; 34:1667-73. [PMID: 25987245 DOI: 10.1007/s10096-015-2403-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2015] [Accepted: 05/03/2015] [Indexed: 11/25/2022]
Abstract
Enterococci are of considerable relevance in the hospital setting. Their most common location is the urinary tract, where they may be responsible for both colonization and infections. They are often associated with the presence of other microorganisms. The aim was to compare monomicrobial and polymicrobial Enterococcus faecalis bacteriuria. A retrospective study was performed on the demographic, clinical, and laboratory data of 299 patients who had presented with E. faecalis bacteriuria in 2012 at a University Hospital. The bacteriuria was polymicrobial in 46.1 % of cases and in 36.4 % of cases was responsible for a urinary tract infection. Infections appeared to be more prevalent in the polymicrobial than the monomicrobial group (42 % vs 32 %, p = 0.06). Half of the patients who presented with urinary tract colonization received antibiotic treatment (54/ out of 10). A multivariate analysis adjusted for age (adjusted odds ratio [AOR] = 1.02 per year, p = 0.006), gender (AOR = 2.2, p = 0.007), and clinical classification (colonization or infection, AOR = 1.6, p = 0.091), showed that diabetes mellitus (AOR = 2.0, p = 0.04), hospital length of stay exceeding 28 days (AOR = 2.0, p = 0.03), and presence of a urinary catheter (AOR = 2.4, p = 0.001) were all factors associated with polymicrobial E. faecalis bacteriuria. A reduction in the length of hospital stay and the use of urinary catheters would appear to be required to decrease the incidence of urinary tract colonization and infections by polymicrobial E. faecalis. Improper use of antibiotics to treat urinary tract colonization remains a major concern.
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Affiliation(s)
- C Fourcade
- Infectious and Tropical Diseases Unit, Nîmes University Hospital, Place du Professeur Robert Debré, 30029, Nîmes cedex 9, France,
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Chong JT, Klausner AP, Petrossian A, Byrne MD, Moore JR, Goetz LL, Gater DR, Mayer Grob B. Pre-procedural antibiotics for endoscopic urological procedures: Initial experience in individuals with spinal cord injury and asymptomatic bacteriuria. J Spinal Cord Med 2015; 38:187-92. [PMID: 24621035 PMCID: PMC4397200 DOI: 10.1179/2045772313y.0000000185] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
Abstract
OBJECTIVE The objective of this study was to compare the safety, efficacy, quality-of-life impact, and costs of a single dose or a longer course of pre-procedural antibiotics prior to elective endoscopic urological procedures in individuals with spinal cord injury and disorders (SCI/D) and asymptomatic bacteriuria. DESIGN A prospective observational study. SETTING Hunter Holmes McGuire Veterans Affairs Medical Center, Richmond, Virginia, USA. PARTICIPANTS Sixty persons with SCI/D and asymptomatic bacteriuria scheduled to undergo elective endoscopic urological procedures. INTERVENTIONS A single pre-procedural dose of antibiotics vs. a 3-5-day course of pre-procedural antibiotics. OUTCOME MEASURES Objective and subjective measures of health, costs, and quality of life. RESULTS There were no significant differences in vital signs, leukocytosis, adverse events, and overall satisfaction in individuals who received short-course vs. long-course antibiotics. There was a significant decrease in antibiotic cost (33.1 ± 47.6 vs. 3.6 ± 6.1 US$, P = 0.01) for individuals in the short-course group. In addition, there was greater pre-procedural anxiety (18 vs. 0%, P < 0.05) for individuals who received long-course antibiotics. CONCLUSION SCI/D individuals with asymptomatic bacteriuria may be able to safely undergo most endoscopic urological procedures with a single dose of pre-procedural antibiotics. However, further research is required and even appropriate pre-procedural antibiotics may not prevent severe infections.
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Affiliation(s)
- Julio T. Chong
- Department of Surgery/Division of Urology, Virginia Commonwealth University School of Medicine, Richmond, VA, USA
| | - Adam P. Klausner
- Correspondence to: Adam P. Klausner, Department of Surgery/Division of Urology, Virginia Commonwealth University School of Medicine, PO Box 980118, Richmond, VA 23298-0118, USA.
| | - Albert Petrossian
- Department of Surgery/Division of Urology, Virginia Commonwealth University School of Medicine, Richmond, VA, USA
| | - Michael D. Byrne
- Department of Surgery/Division of Urology, Virginia Commonwealth University School of Medicine, Richmond, VA, USA
| | - Jewel R. Moore
- Department of Physical Medicine & Rehabilitation, Virginia Commonwealth University, Richmond, VA, USA
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Comparison of bacterial strains and antibiotic susceptibilities in urinary isolates of spinal cord injury patients from the community and hospital. Spinal Cord 2014; 52:298-301. [PMID: 24513724 DOI: 10.1038/sc.2014.10] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2013] [Revised: 01/06/2014] [Accepted: 01/13/2014] [Indexed: 01/18/2023]
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Togan T, Azap OK, Durukan E, Arslan H. The prevalence, etiologic agents and risk factors for urinary tract infection among spinal cord injury patients. Jundishapur J Microbiol 2014; 7:e8905. [PMID: 25147663 PMCID: PMC4138667 DOI: 10.5812/jjm.8905] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2012] [Revised: 01/23/2013] [Accepted: 02/19/2013] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Urinary tract infections (UTIs) are important causes of morbidity and mortality in patients with spinal cord injury and 22% of patients with acute spinal cord injury develop UTI during the first 50 days. OBJECTIVES The aim of this study was to determine the prevalence, etiologic agents and risk factors for asymptomatic bacteriuria and symptomatic urinary tract infections in patients with spinal cord injury. PATIENTS AND METHODS This was a prospective investigation of spinal cord injury patients with asymptomatic bacteriuria and symptomatic urinary tract infections in Baskent University Medical Faculty Ayas Rehabilitation Center and Ankara Physical Therapy and Rehabilitation Center between January 2008 and December 2010. The demographic status, clinical and laboratory findings of 93 patients with spinal cord injury were analyzed in order to determine the risk factors for asymptomatic or symptomatic bacteriuria. RESULTS Sixty three (67.7%) of 93 patients had asymptomatic bacteriuria and 21 (22.6%) had symptomatic urinary tract infection. Assessment of the frequency of urinary bladder emptying methods revealed that 57 (61.3%) of 93 patients employed permanent catheters and 24 (25.8%) employed clean intermittent catheterization. One hundred and thirty-five (48.0%) of 281 strains isolated form asymptomatic bacteriuria attacks and 16 (66.6%) of 24 strains isolated from symptomatic urinary tract infection attacks, totaling 151 strains, had multidrug resistance (P > 0.05). One hundred (70.4%) of 142 Escherichia coli strains and 19 (34.5%) of 55 Klebsiella spp strains proliferated in patients with asymptomatic bacteriuria; 8 (80%) of 10 E. coli strains and 4 (80%) of 5 Klebsiella spp. strains were multidrug resistant. CONCLUSIONS The most common infectious episode among spinal cord injury patients was found to be urinary tract ınfection. E. coli was the most common microorganism isolated from urine samples. Antibiotic use in the previous 2 weeks or 3 months, hospitalization during the last one-year and previous diagnosis of urinary tract ınfection were the risk factors identified for the development of infections with multi-drug resistant isolates. Urinary catheterization was found to be the only independent risk factor contributing to symptomatic urinary tract infection.
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Affiliation(s)
- Turhan Togan
- Department of Infectious Diseases and Clinical Microbiology, Faculty of Medicine, Baskent University, Ankara, Turkey
| | - Ozlem Kurt Azap
- Department of Infectious Diseases and Clinical Microbiology, Faculty of Medicine, Baskent University, Ankara, Turkey
| | - Elif Durukan
- Department of Public Health, Baskent University Faculty of Medicine, Ankara, Turkey
| | - Hande Arslan
- Department of Infectious Diseases and Clinical Microbiology, Faculty of Medicine, Baskent University, Ankara, Turkey
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Goetz LL, Cardenas DD, Kennelly M, Bonne Lee BS, Linsenmeyer T, Moser C, Pannek J, Wyndaele JJ, Biering-Sorensen F. International Spinal Cord Injury Urinary Tract Infection Basic Data Set. Spinal Cord 2013; 51:700-4. [PMID: 23896666 DOI: 10.1038/sc.2013.72] [Citation(s) in RCA: 61] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2013] [Revised: 06/01/2013] [Accepted: 06/03/2013] [Indexed: 11/09/2022]
Abstract
OBJECTIVES To develop an International Spinal Cord Injury (SCI) Urinary Tract Infection (UTI) Basic Data Set presenting a standardized format for the collection and reporting of a minimal amount of information on UTIs in daily practice or research. SETTING International working group. METHODS The draft of the Data Set developed by a working group was reviewed by the Executive Committee of the International SCI Standards and Data Sets, and later by the International Spinal Cord Society (ISCoS) Scientific Committee and the American Spinal Injury Association (ASIA) Board. Relevant and interested scientific and professional (international) organizations and societies (∼40) were also invited to review the data set, and it was posted on the ISCoS and ASIA websites for 3 months to allow comments and suggestions. The ISCoS Scientific Committee, Executive Committee and ASIA Board received the data set for final review and approval. RESULTS The International SCI UTI Basic Data Set includes the following variables: date of data collection, length of time of sign(s)/symptom(s), results of urine dipstick test for nitrite and leukocyte esterase, urine culture results and resistance pattern. The complete instructions for data collection and the data form itself are freely available on the website of ISCoS (http://www.iscos.org.uk).
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Affiliation(s)
- L L Goetz
- Spinal Cord Injury and Disorders Unit, Hunter Holmes McGuire VA Medical Center, Physical Medicine and Rehabilitation, Virginia Commonwealth University, Richmond, VA, USA.
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Bermingham SL, Hodgkinson S, Wright S, Hayter E, Spinks J, Pellowe C. Intermittent self catheterisation with hydrophilic, gel reservoir, and non-coated catheters: a systematic review and cost effectiveness analysis. BMJ 2013; 346:e8639. [PMID: 23303886 PMCID: PMC3541473 DOI: 10.1136/bmj.e8639] [Citation(s) in RCA: 74] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/10/2012] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To determine the most effective and cost effective type of catheter for patients performing intermittent self catheterisation in the community. DESIGN Systematic review and meta-analysis. Results were incorporated into a probabilistic Markov model to compare lifetime costs and quality adjusted life years (QALYs). DATA SOURCES We searched Medline, Embase, and Cochrane and Cinahl databases from 2002 to 18 April 2011 to identify studies comparing hydrophilic, gel reservoir, and non-coated intermittent catheters. Earlier guidelines were used to identify papers published before 2002. To capture studies comparing clean and sterile non-coated intermittent self catheterisation, each database was searched from its date of inception to 18 April 2011. MAIN OUTCOME MEASURES Clinical outcomes included symptomatic urinary tract infection (UTI), bacteraemia, mortality, patient preference or comfort, and number of catheters used. The economic model included downstream complications of UTI and cost effectiveness was calculated as incremental cost per QALY gained. RESULTS Eight studies were included in the systematic review. Most were conducted in patients with spinal cord injuries, and most of the included patients were men. People using gel reservoir and hydrophilic catheters were significantly less likely to report one or more UTIs compared with sterile non-coated catheters (absolute effect for gel reservoir = 149 fewer per 1000 (95% confidence interval -7 to 198), P=0.04; absolute effect for hydrophilic = 153 fewer per 1000 (-8 to 268), P=0.04). However, there was no difference between hydrophilic and sterile non-coated catheters when outcomes were measured as mean monthly UTIs (mean difference = 0.01 (-0.11 to 0.09), P=0.84) or total UTIs at 1 year (mean difference = 0.18 (-0.50 to 0.86), P=0.60). There was little difference in the incidence of one or more UTIs for people using clean versus sterile non-coated catheters (absolute effect = 12 fewer per 1000 (-134 to 146), P=0.86). Although the most effective, gel reservoir catheters cost >£54,350 per QALY gained and are therefore not cost effective compared with clean non-coated self catheterisation. CONCLUSION The type of catheter used for intermittent self catheterisation seems to make little difference to the risk of symptomatic UTI. Given large differences in resource use, clean non-coated catheters are most cost effective. However, because of limitations and gaps in the evidence base and the designation of non-coated catheters as single use devices, we recommend a precautionary principle should be adopted and that patients should be offered a choice between hydrophilic and gel reservoir catheters.
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Affiliation(s)
- Sarah L Bermingham
- Royal College of Physicians, National Clinical Guideline Centre, London NW1 4LE, UK
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Lee BSB, Bhuta T, Simpson JM, Craig JC. Methenamine hippurate for preventing urinary tract infections. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2012. [PMID: 23076896 DOI: 10.1002/14651858.cd003265.pub3.] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Methenamine salts are often used as an alternative to antibiotics for the prevention of urinary tract infection (UTI). This review was first published in Issue 1, 2002 and updated in Issue 4, 2007. OBJECTIVES To assess the benefits and harms of methenamine hippurate in preventing UTI. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL in The Cochrane Library), MEDLINE (from 1950), EMBASE (from 1980), reference lists of articles and abstracts from conference proceedings without language restriction. Manufacturers' of methenamine salts were contacted for unpublished studies and contact was made with known investigators.Date of last search: June 2012 SELECTION CRITERIA Randomised controlled trials (RCT) and quasi-RCTs of methenamine hippurate used for the prevention of UTIs in all population groups were eligible. A comparison with a control/no treatment group was a prerequisite for selection. DATA COLLECTION AND ANALYSIS Two authors independently assessed study quality and extracted data. Statistical analyses were performed using the random effects model and the results expressed as risk ratio (RR) for dichotomous outcomes with 95% confidence intervals (CI). An exploration of heterogeneity and a detailed description of results, grouped by population, was undertaken. MAIN RESULTS Thirteen studies (2032 participants) were included. Six studies (654 patients) reported symptomatic UTI and eight studies (796 patients) reported bacteriuria. Overall, study quality was mixed. The overall pooled estimates for the major outcome measures were not interpretable because of underlying heterogeneity. Subgroup analyses suggested that methenamine hippurate may have some benefit in patients without renal tract abnormalities (symptomatic UTI: RR 0.24, 95% CI 0.07 to 0.89; bacteriuria: RR 0.56, 95% CI 0.37 to 0.83), but not in patients with known renal tract abnormalities (symptomatic UTI: RR 1.54, 95% CI 0.38 to 6.20; bacteriuria: RR 1.29, 95% CI 0.54 to 3.07). For short-term treatment duration (1 week or less) there was a significant reduction in symptomatic UTI in those without renal tract abnormalities (RR 0.14, 95% CI 0.05 to 0.38). The rate of adverse events was low. AUTHORS' CONCLUSIONS Methenamine hippurate may be effective for preventing UTI in patients without renal tract abnormalities, particularly when used for short-term prophylaxis. It does not appear to work in patients with neuropathic bladder or in patients who have renal tract abnormalities. The rate of adverse events was low, but poorly described.There is a need for further large well-conducted RCTs to clarify this question, particularly for longer term use for people without neuropathic bladder.
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Affiliation(s)
- Bon San B Lee
- SpinalMedicine Department, Prince ofWalesHospital, Randwick, Australia.
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Abstract
BACKGROUND Methenamine salts are often used as an alternative to antibiotics for the prevention of urinary tract infection (UTI). This review was first published in Issue 1, 2002 and updated in Issue 4, 2007. OBJECTIVES To assess the benefits and harms of methenamine hippurate in preventing UTI. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL in The Cochrane Library), MEDLINE (from 1950), EMBASE (from 1980), reference lists of articles and abstracts from conference proceedings without language restriction. Manufacturers' of methenamine salts were contacted for unpublished studies and contact was made with known investigators.Date of last search: June 2012 SELECTION CRITERIA Randomised controlled trials (RCT) and quasi-RCTs of methenamine hippurate used for the prevention of UTIs in all population groups were eligible. A comparison with a control/no treatment group was a prerequisite for selection. DATA COLLECTION AND ANALYSIS Two authors independently assessed study quality and extracted data. Statistical analyses were performed using the random effects model and the results expressed as risk ratio (RR) for dichotomous outcomes with 95% confidence intervals (CI). An exploration of heterogeneity and a detailed description of results, grouped by population, was undertaken. MAIN RESULTS Thirteen studies (2032 participants) were included. Six studies (654 patients) reported symptomatic UTI and eight studies (796 patients) reported bacteriuria. Overall, study quality was mixed. The overall pooled estimates for the major outcome measures were not interpretable because of underlying heterogeneity. Subgroup analyses suggested that methenamine hippurate may have some benefit in patients without renal tract abnormalities (symptomatic UTI: RR 0.24, 95% CI 0.07 to 0.89; bacteriuria: RR 0.56, 95% CI 0.37 to 0.83), but not in patients with known renal tract abnormalities (symptomatic UTI: RR 1.54, 95% CI 0.38 to 6.20; bacteriuria: RR 1.29, 95% CI 0.54 to 3.07). For short-term treatment duration (1 week or less) there was a significant reduction in symptomatic UTI in those without renal tract abnormalities (RR 0.14, 95% CI 0.05 to 0.38). The rate of adverse events was low. AUTHORS' CONCLUSIONS Methenamine hippurate may be effective for preventing UTI in patients without renal tract abnormalities, particularly when used for short-term prophylaxis. It does not appear to work in patients with neuropathic bladder or in patients who have renal tract abnormalities. The rate of adverse events was low, but poorly described.There is a need for further large well-conducted RCTs to clarify this question, particularly for longer term use for people without neuropathic bladder.
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Affiliation(s)
- Bon San B Lee
- SpinalMedicine Department, Prince ofWalesHospital, Randwick, Australia.
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DeVivo M, Farris V. Causes and Costs of Unplanned Hospitalizations Among Persons with Spinal Cord Injury. Top Spinal Cord Inj Rehabil 2011. [DOI: 10.1310/sci1604-53] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Fatal Septicaemia Following Suprapubic Cystostomy in a Paraplegic Patient: Never Do a Cystostomy without Prior Urine Culture and Appropriate Antibiogram! Case Rep Med 2010; 2010:461514. [PMID: 20589219 PMCID: PMC2892669 DOI: 10.1155/2010/461514] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2010] [Revised: 04/23/2010] [Accepted: 05/11/2010] [Indexed: 11/18/2022] Open
Abstract
Neuropathic urinary bladder is often colonised by multidrug-resistant bacteria. We report a 64-year-old male spinal cord injury patient with paraplegia, who received gentamicin on empirical basis before undergoing suprapubic cystostomy, as antibiotic sensitivity report of urine was not available. This patient developed fulminate septicaemia. Although appropriate antibiotic therapy (meropenem) was started when this patient manifested features of sepsis, acute renal failure occurred and he expired. Inappropriate initial antimicrobial therapy was the major contributory factor for this patient's mortality. Learning points from this case are (1) never do a cystostomy without prior urine culture and appropriate antibiogram; (2) in a chronic spinal cord injury patient, full blood count, liver function tests, albumin level, and albumin to globulin ratio should be performed before any surgical procedure.
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Infectious complications in patients with chronic bacteriuria undergoing major urologic surgery. Urology 2009; 75:77-82. [PMID: 19931893 DOI: 10.1016/j.urology.2009.09.022] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2009] [Revised: 08/14/2009] [Accepted: 09/10/2009] [Indexed: 11/24/2022]
Abstract
OBJECTIVES To review our perioperative antibiotic management of patients with chronic bacteriuria who underwent urological procedures, and the relationship to postoperative infectious complications. METHODS Between January 2002 and January 2007, 77 patients with chronic bacteriuria underwent 94 major open procedures, including ileocystoplasty (n = 53), ileal conduit (n = 19), and pubovaginal sling placement (n = 18). Admission urine cultures were classified as "sensitive" (sensitive to admission antibiotics or no growth), "resistant" (resistant to admission antibiotics), and "unknown" (multiple unspeciated organisms present or no admission culture data available). RESULTS Our rate of multidrug resistance bacteriuria was 46.3%. There were 7 febrile urinary tract infections, 12 wound infections, 1 episode of sepsis, and no intra-abdominal abscesses, yielding an infectious complication rate of 20.2%. There was no statistical relationship between urine culture status and the rate of febrile urinary tract infections or sepsis, but wound infections were less common in patients with "sensitive" urine cultures. Of the patients who had urine cultures that demonstrated multiple unspeciated organisms, 32% were complicated by wound infections. On multivariate analysis, gender, age, and body mass index were associated with the development of infectious complications. CONCLUSIONS In a medically complex population of patients, those with neurogenic bladder and frequent catheterization undergoing major abdominal surgery, we demonstrate an infectious complication rate of 20.2%. Wound infections were as common in patients whose urine cultures revealed multiple unspeciated organisms as those that were resistant to the perioperative antibiotics, and in this population, further characterization may allow for more appropriate perioperative coverage and a decreased rate of wound infections.
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Predictors and outcomes of antibiotic adequacy for bloodstream infections in veterans with spinal cord injury. Arch Phys Med Rehabil 2009; 90:1364-70. [PMID: 19651270 DOI: 10.1016/j.apmr.2009.02.012] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2008] [Revised: 01/15/2009] [Accepted: 02/04/2009] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To identify predictors and outcomes associated with receiving inadequate empirical antimicrobial treatment for bloodstream infections (BSIs) in persons with spinal cord injury (SCI). DESIGN Retrospective cohort study from October 1, 1997, through September 30, 2004. SETTING A Department of Veterans Affairs SCI center that serves approximately 700 patients a year. PARTICIPANTS Hospitalized patients with SCI (N=123) who had 1 or more BSIs during the study period. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Adequacy of antimicrobial treatment (inadequate treatment was defined as the absence of antimicrobial agents for a particular organism within 2 days after the collection of blood cultures and/or the microorganism's resistance to the antimicrobial administered), hospital length of stay (LOS) post-BSI infection, and in-hospital and 30-day mortality. Cluster-adjusted multivariable models were assessed. RESULTS Over one third (88; 37.4%) of the 235 episodes of BSI identified received inadequate empirical antibiotic treatment. Having a polymicrobial BSI was associated with inadequate treatment (odds ratio [OR]=3.28; 95% confidence interval [CI]=1.62-6.65; P=.001). Factors protective against inadequate therapy included having a comorbid pressure ulcer (OR=0.37; 95% CI=0.21-0.68; P=.001) or a BSI that was not primary (OR=0.30; 95% CI=0.15-0.58; P<.0001). Mortality did not differ between the inadequate and adequate treatment groups (11.4% vs 10.9%; P=.92). Similarly LOS postinfection was not affected by treatment status (inadequate treatment median=22d vs adequate treatment median=27d; P=.98). CONCLUSIONS Over one third of patients received inadequate empirical treatment, which was associated with having a polymicrobial BSI. However, inadequate treatment was not associated with increased mortality or LOS postinfection.
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Everaert K, Lumen N, Kerckhaert W, Willaert P, van Driel M. Urinary tract infections in spinal cord injury: prevention and treatment guidelines. Acta Clin Belg 2009; 64:335-40. [PMID: 19810421 DOI: 10.1179/acb.2009.052] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
OBJECTIVES AND METHODS The literature on prevention and therapy of urinary tract infection (UTI) in patients with spinal cord injury (SCI) was reviewed using 3 levels of evidence. RESULTS Antibiotic therapy is only indicated in symptomatic bacteriuria or in symptomatic exacerbations of chronic UTI. During the acute phase of a SCI, UTI's are more prevalent and bacteria are different and more resistant to antibiotics compared with the chronic phase of SCI. In SCI in general, routine screening urine cultures are not valuable as a high species turn over is seen. Intermittent catheterisation, tapping or Crédé manoeuvre coincide significantly with lower frequency of UTI compared to permanent catheter drainage. No measures are proven efficient in the long term in prevention of bacteriuria or UTI. Methenamine salts are perhaps useful in the prevention of UTI but not in patients with a permanent catheter (level III). Antibiotic prophylaxis was found useful in reducing asymptomatic bacteriuria but not in the prevention of symptomatic infections (level I). However, during prophylaxis a doubling of antibiotic resistance was found. In patients with augmented bladder antibiotic prophylaxis is useless (level II). In chronic SCI the first choice antibiotics are nitrofurantoin or trimethoprim, the second choice are fluoroquinolones (level III) whereas in acute SCI a higher resistance profile to antibiotics is frequent and therefore fluoroquinolones or cefuroxime are suggested (level III). There is no consensus in the literature but we suggest 5 days of antibiotic treatment in UTI during chronic SCI without fever, 7 days in acute SCI without fever and a minimum of 14 days in patients with UTI and fever (level III).
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Affiliation(s)
- K Everaert
- Department of Urology, Ghent University hospital, Ghent, Belgium.
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Dedeić-Ljubović A, Hukić M. Catheter-related urinary tract infection in patients suffering from spinal cord injuries. Bosn J Basic Med Sci 2009; 9:2-9. [PMID: 19284388 DOI: 10.17305/bjbms.2009.2849] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Urinary tract infection is commoner in patients with spinal cord injuries because of incomplete bladder emptying and the use of catheters that can result in the introduction of bacteria into the bladder. 145 patients suffering from spinal cord injuries, admitted to the Institute for physical medicine and rehabilitation, Centre for paraplegia of the Clinical Centre of the University of Sarajevo, were included. The patients were divided in three groups according to the method of bladder drainage: Group A (n=61) consisted of patients on clean intermittent catheterization; Group B (n=54) consisted of patients with indwelling catheters; Group C (n=30) consisted of patients who had performed self-catheterization. From a total of 4539 urine samples, 3963 (87,3%) were positive and 576 (12,7%) were sterile. More than 90% of the infected patients were asymptomatic. The overall rate of urinary infection amounted to about 2,1 episodes, and bacteriuria to 8,1 episodes per patient. 77% of infections (113/145) were acquired within seven days from catheterization. Infection was usually polymicrobial; the greatest number of urine samples 1770/3943 (44,9%) included more than one bacterium. The vast majority of cases of urinary tract infection and bacteriuria are caused by Gram-negative bacilli and enterococci, commensal organisms of the bowel and perineum, representative of those from the hospital environment. Providencia stuarti (18,9%) being the most common, followed by Proteus mirabilis (16,3%), Escherichia coli (11,8%), Pseudomonas aeruginosa (10,2%), Klebsiella pneumoniae (8,1%), Morganella morgani (5,4%), Acinetobacter baumannii (4,6%), Providencia rettgeri (3,5%). 15,7% of isolates were Gram-positive with Enterococcus faecalis (8,6%) as the most common. 55,3% of isolates were multidrug-resistant, and the highest rates of resistance were found among Acinetobacter baumannii (87,8%), Providencia rettgeri (86,7%), Pseudomonas aeruginosa (85,4%), Providencia stuarti (84,3%) and Morganella morgani (81,0%). Lower rates of resistance were found in Group C, i.e. patients on intermittent self-catheterisation. Eradication of organisms was achieved in only 53 (10,05%) of patients; hence, antibiotic therapy had no or very low effect. Significant correlations were found between the method of catheterization and the frequency of bacteriuria and urinary tract infections. The analysis of Group C showed a rate of lower urinary tract infection and bacteriuria than the other two Groups of patients. The objective of this study is the update of etiology and antimicrobial susceptibility in urinary tract infections in this group of patients. In addition, possible correlations between UTI and the type of bladder management were examined.
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Affiliation(s)
- Amela Dedeić-Ljubović
- Institute of Clinical Microbiology, Clinical Centre of the University of Sarajevo, Bolnicka 25, 71000 Sarajevo, Bosnia and Herzegovina
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Evans CT, Hershow RC, Chin A, Foulis PR, Burns SP, Weaver FM. Bloodstream infections and setting of onset in persons with spinal cord injury and disorder. Spinal Cord 2009; 47:610-5. [PMID: 19238165 DOI: 10.1038/sc.2009.2] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
STUDY DESIGN A retrospective cohort study. OBJECTIVE Health-care-associated (HCA) bloodstream infection (BSI) has been shown to be a distinct epidemiologic category in the general adult population, but few studies have examined specific patient populations. The objective of this study was to assess characteristics associated with BSI that occurred in the hospital (hospital-acquired, HA BSI), from health-care contact outside the hospital (HCA BSI) or in the community (community-acquired, CA BSI) in veterans with spinal cord injury and disorder (SCI&D). SETTING Two United States Department of Veterans Affairs hospitals. METHODS All patients with SCI&D with a positive blood culture admitted to study hospitals over a 7-year period (1 October 1997 to 30 September 2004). Demographics, medical characteristics and causative organisms were collected. RESULTS Four hundred and thirteen episodes of BSI occurred in 226 patients, with a rate of 7.2 BSI episodes per 100 admissions: 267 (64.7%) were HA BSI, 110 (26.6%) were HCA BSI and 36 (8.7%) were CA BSI. Antibiotic resistance was more common in those with HA BSI (65.5%) compared with that in those with HCA (49.1%, P=0.001) and CA BSI (22.2%, P<0.0001). Methicillin resistance in Staphylococcus aureus was highly prevalent; HA BSI (84.5%), HCA BSI (60.6%) and CA BSI (33.3%). CONCLUSION HCA BSI comprises one-quarter of all BSIs in hospitalized patients with SCI&D. Although those with HCA and CA BSI share similarities, several differences in medical characteristics and causal microorganism are noted. Treatment and management strategies for HCA and CA infections need to vary.
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Affiliation(s)
- C T Evans
- Department of Veterans Affairs, Center for Management of Complex Chronic Care, Edward Hines Jr. VA Hospital, Hines, IL 60141, USA.
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Abstract
BACKGROUND Methenamine salts are often used as an alternative to antibiotics for the prevention of urinary tract infection (UTI). OBJECTIVES To assess the benefits and harms of methenamine hippurate in preventing UTI. SEARCH STRATEGY We searched the Cochrane Central Register of Controlled Trials (CENTRAL in The Cochrane Library), MEDLINE (from 1950), EMBASE (from 1980), reference lists of articles and abstracts from conference proceedings without language restriction. Manufacturers' of methenamine salts were contacted for unpublished studies and contact was made with known investigators. Date of last search: September 2006 SELECTION CRITERIA Randomised controlled trials (RCT) and quasi-RCTs of methenamine hippurate used for the prevention of UTIs in all population groups were eligible. A comparison with a control/no treatment group was a prerequisite for selection. DATA COLLECTION AND ANALYSIS Two authors independently assessed study quality and extracted data. Statistical analyses were performed using the random effects model and the results expressed as relative risk (RR) for dichotomous outcomes with 95% confidence intervals (CI). An exploration of heterogeneity and a detailed description of results, grouped by population, was undertaken. MAIN RESULTS Thirteen studies (2032 participants) were included. Six studies (654 patients) reported symptomatic UTI and eight studies (796 patients) reported bacteriuria. Overall, study quality was mixed. The overall pooled estimates for the major outcome measures were not interpretable because of underlying heterogeneity. Subgroup analyses suggested that methenamine hippurate may have some benefit in patients without renal tract abnormalities (symptomatic UTI: RR 0.24, 95% CI 0.07 to 0.89; bacteriuria: RR 0.56, 95% CI 0.37 to 0.83), but not in patients with known renal tract abnormalities (symptomatic UTI: RR 1.54, 95% CI 0.38 to 6.20; bacteriuria: RR 1.29, 95% CI 0.54 to 3.07). For short-term treatment duration (1 week or less) there was a significant reduction in symptomatic UTI in those without renal tract abnormalities (RR 0.14, 95% CI 0.05 to 0.38). The rate of adverse events was low. AUTHORS' CONCLUSIONS Methenamine hippurate may be effective for preventing UTI in patients without renal tract abnormalities, particularly when used for short-term prophylaxis. It does not appear to work in patients with neuropathic bladder or in patients who have renal tract abnormalities. The rate of adverse events was low, but poorly described. There is a need for further large well-conducted RCTs to clarify this question, particularly for longer term use for people without neuropathic bladder.
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Affiliation(s)
- B B Lee
- Prince of Wales Hospital, Spinal Injuries Unit, High St, Randwick, NSW, Australia, 2031.
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Roghmann MC, Wallin MT, Gorman PH, Johnson JA. Prevalence and Natural History of Colonization With Fluoroquinolone-Resistant Gram-Negative Bacilli in Community-Dwelling People With Spinal Cord Dysfunction. Arch Phys Med Rehabil 2006; 87:1305-9. [PMID: 17023238 DOI: 10.1016/j.apmr.2006.07.260] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2006] [Accepted: 07/10/2006] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To estimate the prevalence of colonization with fluoroquinolone-resistant gram-negative bacilli (GNB) and to assess risk factors for and define the natural history of colonization. DESIGN Cross-sectional study with follow-up of up to 1 year. SETTING Multiple outpatient sites. PARTICIPANTS Eighty-four community-dwelling adults with spinal cord dysfunction. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURE Colonization of perineum with fluoroquinolone-resistant GNB. RESULTS Overall, 24% of this community-dwelling cohort was colonized with fluoroquinolone-resistant GNB with resistance to both levofloxacin and gatifloxacin. The use of any antibiotic in the last 90 days was most strongly associated with an increased risk of colonization with fluoroquinolone-resistant GNB (relative risk, 2.3; 95% confidence interval, 1.1-4.8; P=.05). Incontinence was significantly more common among those with fluoroquinolone-resistant GNB colonization. Among the participants with incontinence (n=42), the use of intermittent catheterization (vs suprapubic, urethral, or condom catheters or overflow incontinence) was significantly protective. Colonization was not associated with an increase in urinary tract infection and was often transient. CONCLUSIONS Fluoroquinolone resistance among GNB colonizing community-dwelling people with spinal cord dysfunction is common. Colonization is more common among those receiving antibiotics and less common among those continent of urine. Among those with incontinence, those using intermittent catheterization have less colonization.
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Affiliation(s)
- Mary-Claire Roghmann
- VA Maryland Health Care System, University of Maryland School of Medicine, Baltimore, MD, USA.
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Potter PJ. Disordered control of the urinary bladder after human spinal cord injury: what are the problems? PROGRESS IN BRAIN RESEARCH 2006; 152:51-7. [PMID: 16198693 DOI: 10.1016/s0079-6123(05)52004-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/18/2023]
Abstract
Spinal cord injury has a profound impact on the storage and voiding functions of the urinary bladder. Loss of autonomic and somatic control mechanisms leads to hypo- or hyperactivity of the bladder wall and sphincters causing problems that range from incontinence to complete loss of the capacity to empty the bladder. This chapter outlines the types of bladder dysfunction that occur after spinal cord injury, their relative prevalence and current practices used to manage the problems. With all the interventions that are available, management of bladder function often still remains a compromise, as the medications and physical interventions available may stimulate or block components of the voiding reflex, but are often not fully restorative in this effort.
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Affiliation(s)
- Patrick J Potter
- Regional Spinal Cord Injury Rehabilitation Program, and Physical Medicine and Rehabilitation, St. Joseph's Health Center, The University of Western Ontario, London, ON, Canada.
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Waites KB, Canupp KC, Roper JF, Camp SM, Chen Y. Evaluation of 3 methods of bladder irrigation to treat bacteriuria in persons with neurogenic bladder. J Spinal Cord Med 2006; 29:217-26. [PMID: 16859225 PMCID: PMC1864807 DOI: 10.1080/10790268.2006.11753877] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Abstract
BACKGROUND/OBJECTIVE We conducted a randomized, double-blind comparison of twice daily bladder irrigation using 1 of 3 different solutions in community-residing persons with neurogenic bladder who used indwelling catheters to evaluate efficacy in treatment of bacteriuria. METHODS Eighty-nine persons with bacteriuria were randomized to irrigate their bladders twice daily for 8 weeks with 30 mL of (a) sterile saline, (b) acetic acid, or (c) neomycin-polymyxin solution. Urinalysis, cultures, and antimicrobial susceptibility tests were performed at baseline and weeks 2, 4, and 8 to determine the extent to which each of the solutions affected numbers and types of bacteria, urinary pH, urinary leukocytes, and generation of antimicrobial-resistant organisms. RESULTS Bladder irrigation was well tolerated with the exception of 3 participants who had bladder spasms. None of the 3 irrigants had a detectable effect on the degree of bacteriuria or pyuria in 52 persons who completed the study protocol. A significant increase in urinary pH occurred in all 3 groups. No significant development of resistance to oral antimicrobials beyond what was observed at baseline was detected. CONCLUSIONS Bladder irrigation was generally well tolerated for 8 weeks. No advantages were detected for neomycin-polymyxin or acetic acid over saline in terms of reducing the urinary bacterial load and inflammation. We cannot recommend bladder irrigation as a means of treatment for bacteriuria in persons with neurogenic bladder.
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Affiliation(s)
- Ken B Waites
- Department of Pathology, University of Alabama at Birmingham, Birmingham, Alabama, USA.
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García Leoni ME, Esclarín De Ruz A. Management of urinary tract infection in patients with spinal cord injuries. Clin Microbiol Infect 2004; 9:780-5. [PMID: 14616697 DOI: 10.1046/j.1469-0691.2003.00643.x] [Citation(s) in RCA: 91] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Urinary tract infection (UTI) is responsible for major morbidity and mortality in spinal cord injury (SCI) patients. Several factors appear to be responsible for an increased risk of infection in the neurogenic bladder. Incomplete voiding, elevated intravesical pressure and catheter use contribute to an increased risk of symptomatic urinary tract infection. Frequent exposure to antibiotics increases the risk of infection by resistant organisms. UTIs interfere with rehabilitation, and may lead to secondary urologic complications. The classic symptoms of UTI are unreliable indicators in SCI patients with neurogenic bladder. Lack of pyuria reasonably predicts the absence of UTI in SCI patients. Asymptomatic bacteriuria need not be treated with antibiotics. Symptomatic UTI warrants therapy in all patients.
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Affiliation(s)
- M E García Leoni
- Infectious Disease Unit, Department of Internal Medicine, Hospital Nacional de Parapléjicos, Toledo, Spain.
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42
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Prévention des infections urinaires nosocomiales chez le patient ayant une vessie neurologique. Med Mal Infect 2003. [DOI: 10.1016/s0399-077x(03)00160-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Joseph P, de Sèze M, Soyeur L. Qui traiter, quand traiter, comment traiter chez les patients ayant une vessie neurologique ? Med Mal Infect 2003. [DOI: 10.1016/s0399-077x(03)00146-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Groah SL, Stiens SA, Gittler MS, Kirshblum SC, McKinley WO. Spinal cord injury medicine. 5. Preserving wellness and independence of the aging patient with spinal cord injury: a primary care approach for the rehabilitation medicine specialist. Arch Phys Med Rehabil 2002; 83:S82-9, S90-8. [PMID: 11973701 DOI: 10.1053/apmr.2002.32182] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
UNLABELLED This self-directed learning module highlights consideration and treatment of individuals with long-term spinal cord injury (SCI). It is part of the chapter on SCI medicine in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. This article specifically focuses on the challenges of chronic disease prevention, diagnosis, therapeutic options, and the resultant impact on the person with long-term SCI. With cardiovascular disease becoming a leading cause of mortality in this population, risk factor modification through weight, lipid, and glucose control becomes more important. Likewise, bowel dysfunction increases with duration and severity of SCI. Conservative and surgical management options are discussed. Musculoskeletal repetitive trauma injuries occur commonly in long-term SCI but can be prevented with appropriate lifestyle or equipment modifications. These and other conditions occurring in the person with long-term SCI are closely related to psychosocial function with resultant social isolation, depression, and substance abuse. Thus, identification and surveillance of these comorbidities are addressed, with an emphasis on prevention. OVERALL ARTICLE OBJECTIVE To summarize the unique medical, psychosocial, and functional needs of the individual with long-term SCI.
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Affiliation(s)
- Suzanne L Groah
- Department of Physical Medicine and Rehabilitation, Santa Clara Valley Medical Center, San Jose, CA 95118, USA.
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Biering-Sørensen F, Bagi P, Høiby N. Urinary tract infections in patients with spinal cord lesions: treatment and prevention. Drugs 2002; 61:1275-87. [PMID: 11511022 DOI: 10.2165/00003495-200161090-00004] [Citation(s) in RCA: 76] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
Even though the mortality due to urinary tract complications has decreased dramatically during the last decades in individuals with spinal cord lesions (SCL), urinary tract infections (UTI) still cause significant morbidity in this population. Complicated UTI are caused by a much wider variety of organisms in individuals with SCL than in the general population and are often polymicrobial. 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 SCL. There is no doubt that the greatest risk for complicated UTI in these individuals is the use of an indwelling catheter. Intermittent catheterisation during the rehabilitation phase has been shown to lower the rate of UTI, and virtually eliminate many of the complications associated with indwelling catheters. Persons with SCL should only be treated for bacteriuria if they have symptoms. Generally, it is advisable to use antibacterial agents with little or no impact on the normal flora. Single agent therapy - in accordance with antimicrobial susceptibility test - is preferred. We advise extending treatment to at least 5 days, and in those with reinfection or relapsing UTI, at least 7 to 14 days, depending on the severity of the infection. The diagnosis of structural and/or functional risk factors is essential in order to plan an optimal treatment for UTI in individuals with SCL, which should include treatment of simultaneously occurring predisposing factors. The treatment of structural risk factors follows general urological principles, aiming for sufficient outlet from the bladder with minimal residual urine and low pressure voiding. For prevention of UTI, general cleanliness and local hygiene should be encouraged. If the patient has a reinfection or relapsing symptomatic UTI, it is important to check for inadequately treated infection and complications, which need special attention, in particular residual urine and urinary stones. No reliable evidence exists of the effectiveness of cranberry juice and other cranberry products. Prophylactic antibacterials should only be used in patients with recurrent UTI where no underlying cause can be found and managed, and in particular if the upper urinary tract is dilated. Antibacterials should not be used for the prevention of UTI in individuals with SCL and indwelling catheters. However, the use of prophylactic antibacterials for individuals with SCL using intermittent catheterisation or other methods of bladder emptying is controversial.
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Affiliation(s)
- F Biering-Sørensen
- Clinic for Para- and Tetraplegia, Copenhagen University Hospital, Rigshospitalet, Denmark.
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Abstract
Urinary tract infection is the most frequently reported secondary impairment in individuals with spinal cord lesion. The most prevalent risk indicator is an indwelling catheter. Hydrophilic catheters for clean intermittent catheterization may induce lower rates of bacteriuria and long-term urethral complications. Due to chronic bacterial infection within biofilms, an antibacterial treatment based on a urinary culture of bacteria in the urine and its antimicrobial susceptibility may fail to eradicate catheter-associated urinary tract infection. No commercially available drugs are sufficiently active against the bacteria in a mature biofilm. Biomaterials may be modified to decrease the formation of a biofilm. Silver alloy catheters are effective in preventing urinary tract infection when indwelling urinary catheterization is necessary. The risk of systemic argyria in long-term use needs to be evaluated. Suprapubic cystostomy drainage in patients with neurogenic bladder is preferred to an indwelling urethral catheter. In cases of recurring urinary tract infection in patients with a permanent urinary catheter, it may be beneficial to change the catheter every 1 or 2 weeks. There is some evidence that cranberry products may prevent urinary tract infection. In the future, bacterial interference and vaccination may be a possibility for prevention of urinary tract infection.
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Chen Y, DeVivo MJ, Lloyd LK. Bladder stone incidence in persons with spinal cord injury: determinants and trends, 1973-1996. Urology 2001; 58:665-70. [PMID: 11711333 DOI: 10.1016/s0090-4295(01)01374-7] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVES To examine the current trend in the incidence of an initial bladder stone and the potential contributing factors among persons with spinal cord injury. METHODS A longitudinal cohort of 1336 patients with spinal cord injury who were injured between 1973 and 1996 and followed up on a yearly basis up to 1999 in a single institution was used to estimate bladder stone incidence. Multivariable analysis was performed to identify risk factors for an initial bladder stone. RESULTS During the study period, 229 incident bladder stone cases were documented. It is estimated that for those injured in 1973 to 1979, 1980 to 1984, 1985 to 1989, and 1990 to 1996, the 5-year cumulative incidence rate of an initial bladder stone was 29%, 23%, 14%, and 8%, respectively (P <0.0001). This decreasing trend was consistent for various demographic and clinical characteristics. During the first year after injury only, the bladder stone risk increased with decreasing age (P <0.0001) and was greater for whites. A neurologically complete lesion was associated with an increased bladder stone risk in later years (P = 0.008). Males and persons with indwelling and intermittent catheters had a higher risk during all the years after the injury. CONCLUSIONS With improvement in urologic rehabilitation, bladder stone incidence has declined during the past several decades. The study results, however, suggest that new strategic interventions may be required to further prevent stone occurrence in individuals with spinal cord injury and a complete neurologic lesion who are using indwelling catheterization, because these patients are still at a relatively higher risk.
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Affiliation(s)
- Y Chen
- Department of Physical Medicine and Rehabilitation, University of Alabama at Birmingham, Birmingham, Alabama, USA
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