Actionable Nuggets for Spinal Cord Injury

13. Recognizing Urinary Tract Infections in SCI Patients

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

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, whereas overtreatment contributes to antibiotic resistance.  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. Significant bacteriuria
    • ≥ 105 cfu/ml in those using intermittent catheterization
    • ≥ 107 cfu/ml for those using external condom collection
    • ≥ 108 cfu/ml for spontaneous bladder management
    • Any detectable concentration in those using indwelling catheters (including urethral and suprapubic catheters)
  2. Pyuria
    • ≥ 50 WBC/hpf
  3. Signs/Symptoms
    • One or more of: (a) discomfort or pain over the kidney or bladder, or dysuria; (b) increased urinary incontinence; (c) increased spasticity; (d) autonomic dysreflexia; (e) cloudy urine with increased odour; (f) fever, malaise, lethargy, or sense of unease.

Quantitative criteria for significant bacteriuria in SCI have excellent sensitivity and specificity for predicting UTI.  It is essential to consider the type of bladder drainage when evaluating bacteriuria.  Recent evidence shows that urine dipstick testing may prove as accurate as microscopy.

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

Additional References (chronological order):

    Cameron, A. P., Lai, J., Saigal, C. S., & Clemens, J. Q. (2015). Urological Surveillance and Medical Complications after Spinal Cord Injury in the United States. Urology, 86(3), 506-510. http://doi.org/10.1016/j.urology.2015.06.005
    McKibben, M. J., Seed, P., Ross, S. S., & Borawski, K. M. (2015). Urinary Tract Infection and Neurogenic Bladder. Urologic Clinics of North America, 42(4), 527–536. http://doi.org/10.1016/j.ucl.2015.05.006
    Schurch, B., Tawadros, C., & Carda, S. (2015). Dysfunction of lower urinary tract in patients with spinal cord injury. Handbook of Clinical Neurology, 130, 247-67. Elsevier.
    Sekulić, A., Karadžov-Nikolić, A., Bukumirić, Z., Trajković, G., Ćorac, A., Janković, S., & Milićević, S. (2015). Analysis of the factors influencing development of urinary tract infections in patients with spinal cord injuries. Vojnosanitetski pregled, 72(12), 1074-1079.
    Nicolle, L. E. (2014a). Urinary tract infections in patients with spinal injuries. Current Infectious Disease Reports, 16(1), 390. http://doi.org/10.1007/s11908-013-0390-9
    Nicolle, L. E. (2014b). Urinary tract infections in special populations. diabetes, renal transplant, HIV infection, and spinal cord injury. Infectious Disease Clinics of North America, 28(1), 91–104. http://doi.org/10.1016/j.idc.2013.09.006
    Goetz, L. L., & Klausner, A. P. (2014). Strategies for prevention of urinary tract infections in neurogenic bladder dysfunction. Physical Medicine and Rehabilitation Clinics of North America, 25(3), 605–618. http://doi.org/10.1016/j.pmr.2014.04.002
    Jahromi, M. S., Mure, A., & Gomez, C. S. (2014). UTIs in Patients with Neurogenic Bladder. Current Urology Reports, 15(9), 1–7. http://doi.org/10.1007/s11934-014-0433-2
    Shigemura, K., Takase, R., Osawa, K., Takaba, K., Nomi, M., Fujisawa, M., & Arakawa, S. (2014). Emergence and prevention measures for multidrug resistant Pseudomonas aeruginosa in catheter-associated urinary tract infection in spinal cord injury patients. Spinal Cord, 53(August), 1–5. http://doi.org/10.1038/sc.2014.154
    Togan, T., Kurt Azap, O., Durukan, E., & Arslan, H. (2014). The prevalence, etiologic agents and risk factors for urinary tract infection among spinal cord injury patients. Jundishapur Journal of Microbiology, 7(1), 1–8. http://doi.org/10.5812/jjm.8905
    Zhang, Z., & Liao, L. (2014). Risk factors predicting upper urinary tract deterioration in patients with spinal cord injury: a prospective study. Spinal Cord, 52(6), 468–71. http://doi.org/10.1038/sc.2014.63
    Böthig, R., Fiebag, K., Thietje, R., Faschingbauer, M., & Hirschfeld, S. (2013). Morbidity of urinary tract infection after urodynamic examination of hospitalized SCI patients: the impact of bladder management. Spinal Cord, 51(1), 70–3. http://doi.org/10.1038/sc.2012.107
    El Masri, W., Patil, S., Prasanna, K., & Chowdhury, J. (2013). To cystoscope or not to cystoscope patients with traumatic spinal cord injuries managed with indwelling urethral or suprapubic catheters? That is the question! Spinal Cord. http://doi.org/10.1038/sc.2013.119
    Goetz, L. L., Cardenas, D. D., Kennelly, M., Lee, B. S. B., Linsenmeyer, T., Moser, C., … Wyndaele, J. (2013). International Spinal Cord Injury Urinary Tract Infection Basic Data Set. Spinal Cord, 51(9), 700–704. http://doi.org/10.1038/sc.2013.72
    Cameron, A. P., Rodriguez, G. M., & Schomer, K. G. (2012). Systematic review of urological follow up after spinal cord injury. The Journal of urology, 187(2), 391-397.
    Everaert, K., Lumen, N., Kerckhaert, W., Willaert, P., & van Driel, M. (2009). Urinary tract infections in spinal cord injury: Prevention and treatment guidelines. Acta Clinica Belgica, 64(4), 335-40.
    Massa, L.M., Hoffman, J.M., & Cardenas, D.D. (2009). Validity, accuracy, and predictive value of urinary tract infection signs and symptoms in individuals with spinal cord injury on intermittent catheterization. Journal of Spinal Cord Medicine, 32(5), 568-73.
    Consortium for Spinal Cord Medicine. (2006). Bladder management for adults with spinal cord injury: a clinical practice guideline for health-care providers. Journal of Spinal Cord Medicine, 29(5), 527-73.
http://www.pva.org/site/News2?news_iv_ctrl=-1&page=NewsArticle&id=7121
    Jayawardena, V., & Midha, M. (2004). Significance of bacteriuria in neurogenic bladder. Journal of Spinal Cord Medicine, 27(2), 102-5. http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=15162878
    Foxman, B. (2002). Epidemiology of urinary tract infections: incidence, morbidity, and economic costs. American Journal of Medicine, 113(Suppl 1A), 5S-13S. http://dx.doi.org/10.1016/S0002-9343(02)01054-9
    National Institute on Disability and Rehabilitation Research. (1993). The prevention and management of urinary tract infections among people with spinal cord injuries. National Institute on Disability and Rehabilitation Research consensus statement, January 27-29, 1992. SCI Nursing, 10(2), 49-61.www.ncbi.nlm.nih.gov/pubmed
    Gribble, M.J., Puterman, M.L., & McCallum, N.M. (1989). Pyuria: its relationship to bacteriuria in spinal cord injured patients on intermittent catheterization. Archives of Physical Medicine & Rehabilitation, 70(5), 376-9. http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=2719541
    Gribble, M.J., McCallum, N.M., & Schechter, M.T. (1988). Evaluation of diagnostic criteria for bacteriuria in acutely spinal cord injured patients undergoing intermittent catheterization. Diagnostic Microbiology and Infectious Disease, 9(4), 197-206.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=3180705
    Deresinski, S.C., & Perkash, I. (1985). Urinary tract infections in male spinal cord injured patients. Part one: Bacteriologic diagnosis. Journal of the American Paraplegia Society, 8(1), 4-6.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=3886842
    Stark, R.P. & Maki, D.G. (1984). Bacteriuria in the catheterized patient. What quantitative level of bacteriuria is relevant? New England Journal of Medicine, 311(9), 560-4.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=6749229