14. Pharmacological Management of UTI in SCI

Recurrent UTIs should be treated as complicated infections. Treatment must be customized to the patient and infecting organism,

The Problem

Recurrent urinary tract infections (UTIs; more than 3 per year) in individuals with neurogenic bladder are a significant health concern. They are often polymicrobial, antibiotic-resistant, and caused by a much wider variety of pathogens than in the general population

Evidence-based Best Practice

There is no superior agent or class of antibiotics for UTIs in spinal cord injury. Research shows the lack of an evidence-based standard of care for urinary tract infections in SCI. Guidelines for selecting antimicrobial agents in SCI patients include: identification of the infecting organism and its antimicrobial susceptibility pattern; and, assessment of host resistance and risk factors.

Once a symptomatic UTI is confirmed in an individual with SCI (see Nugget #13), treatment should be started without waiting for culture results. Short course (3-7 day) treatment may be used for simple infections (frequency of fewer than 3 per year), and long-course (7-14 days) should be prescribed for complex/recurrent UTI (> 3 infections per year).

Survey results show a tendency to over-treat UTIs in patients with SCI, resulting in antibiotic resistance. They also show poor compliance with matching culture sensitivity with antibiotic prescribed. The SCI population currently has higher resistance rates to a number of the usual treatments for bladder infection, such as ampicillin, sulphamethoxazole-trimethaprim and norfloxacin.

Asymptomatic infections should not be treated with antibiotics, due to significant risk of antimicrobial resistance. Antibiotics should not be offered for routine prophylaxis (for example, when changing indwelling catheters). Other emerging preventive treatments include immunomodulation therapy with E. coli fractions, weekly cycling oral antibiotics, and bladder irrigation with antiseptic.

Key Reference

Hill, T. T. C., Baverstock, R., Carlson, K. V, Estey, E. P., Gray, G. J., Hill, D. C., … Parmar, R. (2013). Best practices for the treatment and prevention of urinary tract infection in the spinal cord injured population: The Alberta context. Canadian Urological Association Journal7(3-4), 122–30. http://doi.org/10.5489/cuaj.337

Actionable Nuggets (4th ed., 2019)

Additional References

Dinh, A., Toumi, A., Blanc, C., Descatha, A., Bouchand, F., Salomon, J., . . . Bernard, L. (2016). Management of febrile urinary tract infection among spinal cord injured patients.BMC Infectious Diseases, 16(153), 156. doi:10.1186/s12879-016-1484-4

Krebs, J., Fleischli, S., Stoyanov, J., & Pannek, J. (2019). Effects of oral immunomodulation therapy on urinary tract infections in individuals with chronic spinal cord injury—A retrospective cohort study.Neurourology and Urodynamics, 38(1), 346-352. doi:10.1002/nau.23859

Lee, B. B., Toh, S., Ryan, S., Simpson, J. M., Clezy, K., Bossa, L., . . . Kotsiou, G. (2016). 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 Urology, 16(1), 18. doi:10.1186/s12894-016-0136-8

Okamoto, I., Prieto, J., Avery, M., Moore, K., Fader, M., Sartain, S., & Clancy, B. (2017). Intermittent catheter users’ symptom identification, description and management of urinary tract infection: A qualitative study.BMJ Open, 7(9), e016453. doi:10.1136/bmjopen-2017-016453

Pannek, J., & Wöllner, J. (2017). Management of urinary tract infections in patients with neurogenic bladder: Challenges and solutions.Research and Reports in Urology, 9, 121-127. doi:10.2147/RRU.S113610

Poirier, C., Dinh, A., Salomon, J., Grall, N., Andremont, A., & Bernard, L. (2016). Prevention of urinary tract infections by antibiotic cycling in spinal cord injury patients and low emergence of multidrug resistant bacteria.Médecine Et Maladies Infectieuses, 46(6), 294-299. doi:10.1016/j.medmal.2016.02.010

Toh, S., Boswell-Ruys, C. L., Lee, B. S. B., Simpson, J. M., & Clezy, K. R. (2017). Probiotics for preventing urinary tract infection in people with neuropathic bladder.The Cochrane Database of Systematic Reviews, 9, CD010723. doi:10.1002/14651858.CD010723.pub2