13. Recognizing Urinary Tract Infections in SCI Patients

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

The Problem:Woman sitting in wheelchair

Individuals with spinal cord injury (SCI) have an increased risk of developing urinary tract infections (UTIs). Many individuals with SCI have asymptomatic bacteriuria or cells in their urine, but this does not constitute a UTI.

Actionable Nugget

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

Evidence-based Best Practice:

The diagnosis of UTI by irritative voiding symptoms (dysuria, urgency, polyuria) is made difficult by the presence of sensory impairment in SCI patients. Furthermore, asymptomatic pyuria and / or bacteruria is common in people with SCI. 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
    • ≥ 102 cfu/ml in those using intermittent catheterization
    • ≥ 104 cfu/ml for clean-void specimens from catheter-free males with external condom collection
    • ≥ 104 cfu/ml for spontaneous bladder management
    • Any detectable concentration in those using indwelling catheters
  2. Pyuria
    • ≥ 50 WBC/hpf
  3. Signs/Sysmptoms
    • One or more of: (a) discomfort or pain over the kidney or bladder, or during urination; (b) onset of urinary incontinence; (c) increased spasticity; (d) autonomic dysreflexia; (e) cloudy urine with increased odour; (f) fever, malaise, lethargy, or sense of unease.

The quantitative criteria for significant bacteriuria in SCI have excellent sensitivity and specificity and underscore the need to consider type of bladder drainage when evaluating bacteriuri.

Key reference:

    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.

Additional References:

    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
    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
    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
    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
    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
    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
    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.
    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
    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