14. Pharmacological Management of UTI in SCI

Actionable Nuggets for SCI (3rd ed., 2016)

The Problem:Man in power wheelchair

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.



Actionable Nugget

There is no superior agent or class of antibiotics for UTIs in spinal cord injury.  Recurrent UTIs should be treated as complicated infections, and treatment must be customized to the patient and the infecting organism.

Evidence-based Best Practice:

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.  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.

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).  Routine prophylactic antibiotics should not be offered (for example, when changing indwelling catheters), and asymptomatic infections should not be treated with antibiotics, due to significant risk of antimicrobial resistance.

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 Journal, 7(3-4), 122–30. http://doi.org/10.5489/cuaj.337

Additional references (chronological order):

    Compton, S., Trease, L., Cunningham, C., & Hughes, D. (2015). Australian Institute of Sport and the Australian Paralympic Committee position statement: urinary tract infection in spinal cord injured athletes. British journal of sports medicine49(19), 1236-1240.
    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
    Poirier, C., Dinh, A., Salomon, J., Grall, N., Andremont, A., & Bernard, L. (2015). Antibiotic cycling prevents urinary tract infections in spinal cord injury patients and limits the emergence of multidrug resistant organism. Journal of Infection71(4), 491-493.
    Darouiche, R. O., Al Mohajer, M., Siddiq, D. M., & Minard, C. G. (2014). Short versus long course of antibiotics for catheter-associated urinary tract infections in patients with spinal cord injury: a randomized controlled noninferiority trial. Archives of physical medicine and rehabilitation95(2), 290-296.
    Yoon, S. B., Lee, B. S., Lee, K. D., Hwang, S. I., Lee, H. J., & Han, Z. A. (2014). Comparison of bacterial strains and antibiotic susceptibilities in urinary isolates of spinal cord injury patients from the community and hospital, 52(4), 298–301. http://doi.org/10.1038/sc.2014.10
    Jia, C., Liao, L. M., Chen, G., & Sui, Y. (2013). Detrusor botulinum toxin A injection significantly decreased urinary tract infection in patients with traumatic spinal cord injury. Spinal Cord51(6), 487-490.
     Martins, C. F., Bronzatto, E., Neto, J. M., Magalhães, G. S., D’anconna, C. A. L., & Cliquet, A. (2013). Urinary tract infection analysis in a spinal cord injured population undergoing rehabilitation- how to treat&quest. Spinal cord,51(3), 193-195.
    Bauler, S., Janoly-Dumenil, A., Bassi, S., Luaute, J., Jacquin-Courtois, S., Ciancia, S., … & Rode, G. (2012). Antibiotherapy for urinary tract infections in patient with spinal cord or brain injury: Impact of a professional practices’ clinical audit. Annals of Physical and Rehabilitation Medicine, 55, e300-e301.
    Pannek, J. (2011). Treatment of urinary tract infection in persons with spinal cord injury: guidelines, evidence, and clinical practice. The Journal of Spinal Cord Medicine, 34 (1), 11-15. http://doi.org/10.1179/107902610X12886261091839
     Darouiche, R. O., Green, B. G., Donovan, W. H., Chen, D., Schwartz, M., Merritt, J., … & Hull, R. A. (2011). Multicenter randomized controlled trial of bacterial interference for prevention of urinary tract infection in patients with neurogenic bladder. Urology, 78(2), 341-346.
    Wolfe, D.L., Legassic, M., McIntyre, A., Cheung, K., Goettl, T., Walia, S., Loh, E., et al. (2012). Bladder health and function following spinal cord injury. Spinal Cord Injury Rehabilitation Evidence, Version 4.0, 1-143.
    Zalmanovici Trestioreanu, A., Lador, A., Sauerbrun-Cutler, M.T., & Leibovici, L. (2012). Antibiotics for asymptomatic bacteriuria (Protocol). The Cochrane Library1, 1-11.
    del Popolo, G., Mencarini, M., Nelli, F., & Lazzeri, M. (2012). Controversy over the pharmacological treatments of storage symptoms in spinal cord injury patients: A literature overview. Spinal Cord50, 8-13.
    Ryu, K.H., Kim, Y.B., Yang, S.O., Lee, J.K., & Jung, T.Y. (2011). Results of urine culture and antimicrobial sensitivity tests according to the voiding method over 10 years in patients with spinal cord injury. Korean Journal of Urology, 52(5), 345-9.
    Wilde, M.H., Brasch, J., Getliffe, K., Brown, K.A., McMahon, J.M., Smith, J.A., Anson, E., et al. (2010). Study on the use of long-term urinary catheters in community-dwelling individuals. Journal of Wound, Ostomy and Continence Nursing, 37(3), 301-10.
    Siroky, M.B. (2002). Pathogenesis of bacteriuria and infection in the spinal cord injured patient. American Journal of Medicine113(Suppl 1A), 67S-79S.
    Esclarin De Ruz, A., Garcia Leoni, E., & Herruzo Cabrera, R. (2000). Epidemiology and risk factors for urinary tract infection in patients with spinal cord injury. Journal of Urology164(4), 1285-9. http://dx.doi.org/10.1097/00005392-200010000-00032
    Reid, G., et al. (2000). Ofloxacin for the treatment of urinary tract infections and biofilms in spinal cord injury. The International Journal of Antimicrobial Agents13(4), 305-7.
    Reid, G., et al. (1994). Use of adhesion counts to help predict symptomatic infection and the ability of fluoroquinolones to penetrate bacterial biofilms on the bladder cells of spinal cord injured patients. Paraplegia, 32(7), 468-72. http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=7970848
    Reid, G., et al. (1992). Bacterial biofilm formation in the urinary bladder of spinal cord injured patients. Paraplegia30(10), 711-7. http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=1448299