14. Pharmacological Management of UTI in SCI

Actionable Nuggets for SCI (2nd ed., 2013)

Prescribe fluoroquinolones as first-line for febrile or chronic symptomatic UTI.

The Problem:

Urinary tract infections (UTIs) in individuals with neurogenic bladder are often polymicrobial and caused by a much wider variety of pathogens than in the general population.

Evidence-based Best Practice:

Guidelines for selecting antimicrobial agents in SCI patients are similar to guidelines for the general population. They include identification of the infecting organism and its antimicrobial susceptibility pattern, and assessment of host resistance and risk factors. Once symptomatic UTI is confirmed in an individual with SCI (see Nugget #4), first-line treatment is one of the fluorquinolones (e.g. ciprofloxacin, ofloxacin). Treatment should be started without waiting for culture results, and a minimum of 14 days of treatment should be offered for recurrent UTI. Routine prophylactic antibiotics should not be used when changing catheters, and asymptomatic infections should not be treated with antibiotics, due to significant risk of antimicrobial resistance.

A randomized controlled trial showed a clinical cure rate of 90% for ofloxacin, compared to 57% for trimethoprim-sulphamethoxazole (TMP-SMX) or other antibiotics. In addition, 67% of bacteria were eradicated with ofloxacin compared with 35% for TMP-SMX or other. Another study showed that ciprofloxacin eradicated 92% of bacteria, while ofloxacin did so in 71% and norfloxacin in 56% of cases.

Key reference:

    Zalmanovici Trestioreanu, A., Lador, A., Sauerbrun-Cutler, M.T., & Leibovici, L. (2012). Antibiotics for asymptomatic bacteriuria (Protocol). The Cochrane Library1: 1-11.

Additional references:

    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.
    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. (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
    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. Paraplegia32(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. (2000). Ofloxacin for the treatment of urinary tract infections and biofilms in spinal cord injury. The International Journal of Antimicrobial Agents13(4): 305-7.
    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.
    Siroky, M.B. (2002). Pathogenesis of bacteriuria and infection in the spinal cord injured patient. American Journal of Medicine113(Suppl 1A): 67S-79S.
    Wilde, M.H., Brasch, J., Getliffe, K., Brown, K.A., McMahon, J.M., Smith, J.A., Anson, E., et al. Study on the use of long-term urinary catheters in community-dwelling individuals. Journal of Wound, Ostomy and Continence Nursing, 37(3): 301-10.
    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.