13. Recognizing Urinary Tract Infections in SCI

Diagnosis of UTI in SCI requires three criteria: (1) significant bacteriuria; (2) pyuria; AND (3) signs and symptoms.

The Problem

Individuals with spinal cord injury (SCI) have an increased risk of developing urinary tract infections (UTIs), particularly if they use indwelling or suprapubic catherization. Left untreated, infection can lead to life-threatening autonomic dysreflexia or sepsis. The diagnosis of UTI is complicated in SCI. Irritative voiding symptoms (dysuria, urgency, polyuria) may not exist due to sensory impairment. Furthermore, asymptomatic pyuria and/or bacteruria is common in people with SCI and does not necessarily constitute a UTI.

Evidence-based Best Practice

It is important to distinguish between asymptomatic bacterial colonization (which is virtually inevitable in SCI), and symptomatic infection.  Definitive diagnosis of UTI in SCI therefore requires all three criteria listed below:

  1. Signs/Symptoms — one or more of:
  • discomfort or pain over the kidney or bladder, or dysuria;
  • increased urinary continence;
  • increased spasticity;
  • autonomic dysreflexia;
  • cloudy urine with increased odour;
  • fever, malaise, lethargy, or sense of unease.

2. Significant bacteriuria

  • Any detectable concentration in those using indwelling catheters (including urethral and suprapubic catheters)
  • ≥ 105 cfu/ml in those using intermittent catheterization
  • ≥ 107 cfu/ml for those using external condom collection
  • ≥ 108 cfu/ml for spontaneous bladder management

3. Pyuria — ≥ 50 WBC/hpf

Quantitative criteria for significant bacteriuria in SCI have excellent sensitivity and specificity for predicting UTI.  Recent evidence shows that urine dipstick testing may prove as accurate as microscopy, but neither is definitive for UTI in patients with SCI.

Key Reference

Grabe, M., Bartoletti, R., Johansen, T. E. B., Associate, T. C. G., Çek, M., Associate, B. K. G., & Naber, K. G. (2015). Guidelines on urological Infections by European Association of Urology. Retrieved from http://uroweb.org/wp-content/uploads/19-Urological-infections_LR2.pdf

Actionable Nuggets (4th ed., 2019)

Additional References (since 2016)

Neyaz, O., Srikumar, V., Equebal, A., & Biswas, A. (2018). Change in urodynamic pattern and incidence of urinary tract infection in patients with traumatic spinal cord injury practicing clean self-intermittent catheterization.The Journal of Spinal Cord Medicine, , 1-6. doi:10.1080/10790268.2018.1512729

Nicolle, L. E., Gupta, K., Bradley, S. F., Colgan, R., DeMuri, G. P., Drekonja, D., . . . Siemieniuk, R. (2019). Clinical practice guideline for the management of asymptomatic bacteriuria: 2019 update by the infectious diseases society of America.Clinical Infectious Diseases, 68(10), 1611-1615. doi:10.1093/cid/ciz021

Previnaire, J. G., Soler, J. M., Chouaki, L., Pawlicki, L., Le Berre, M., Hode, E., & Denys, P. (2017). Validity of urine dipstick test to assess eradication of urinary tract infection in persons with spinal cord injury.Progres En Urologie : Journal De l’Association Francaise d’Urologie Et De La Societe Francaise d’Urologie, 27(7), 424.

Skelton, F., Grigoryan, L., Holmes, S. A., Poon, I. O., & Trautner, B. (2018). Routine urine testing at the spinal cord injury annual evaluation leads to unnecessary antibiotic use: A pilot study and future directions.Archives of Physical Medicine and Rehabilitation, 99(2), 219-225. doi:10.1016/j.apmr.2017.10.005

Wikström, M., Levi, R., Antepohl, W., Region Östergötland. (2018). Bladder irrigation with chlorhexidine reduces bacteriuria in persons with spinal cord injury.Journal of Rehabilitation Medicine, 50(2), 181-184. doi:10.2340/16501977-2298