PAKISTAN ARMED FORCES
MEDICAL JOURNAL (Category Y)

A Journal of Army Medical & Dental Corps

Being published since 1956

ISSN (online) 2411-8842
ISSN (print) 0030-9648

VOL 61, No. 3, SEPTEMBER 2011

FREQUENCY OF URINARY TRACT INFECTION (UTI) & COMMONEST CAUSATIVE ORGANISMS IN SPINAL CORD INJURY PATIENTS WITH VARIOUS VOIDING MODES

Farah Mahboob, Nadeem Ahmed*, Farooq Rathore**, Sara Razzq*

Abstract

Objective of study: To determine the frequency of urinary tract infection and commonest causative organisms in spinal cord injury patients with various modes of voiding in rehabilitation setup in Pakistan.
Study Design: A descriptive study of 100 spinal cord injury patients.
Place and Duration of the Study: The Armed Forces Institute of Rehabilitation Medicine (AFIRM) Rawalpindi from September 2007 to March 2008 on clinical samples received from admitted patients in CMH Rawalpindi and AFIRM.
Material and Methods: In 100 patients of spinal cord urine samples were subjected to Urine Routine examination and Urine Culture sensitivity.  Urine culture revealing a bacterial colony count of 105 cfu/ml or higher were considered positive for urinary tract infection (UTI) if present with symptoms. Significant bacteriuria was investigated for spectrum and sensitivity pattern as well.
Results: Of all 100 spinal cord patients 52 patients (52%) had symptoms suggestive of UTI but only 37 patients (37%) had significant bacteriuria on urine culture supported by high level pyuria were declared to have UTI. E-coli was the most commonly isolated organism with total no of 20 cases (54.1%) followed by Pseudomonas 6 cases (16.2%), Klebsiella pneumoniae 3 cases (8.1%),  Proteus mirabilis 3 cases (8.1%), Citrobacter freundi 2 cases (5.4%) and the least frequent was Morganella morganii with 1 case (2.7%). UTI was most frequent in patients with indwelling catheter and  was least  associated with self voiding.
Conclusion: Urinary Tract Infection was commonly observed among spinal cord injury patients. E-coli was the commonest isolated pathogen followed by Pseudomonas, Klebsiella pneumoniae, Proteus mirabilis, Citrobacter freundi, Candida and Morganella morganii in descending order of frequency. UTI was most frequent in patients using indwelling catheter as a mode of voiding.

Keywords : Significant bacteriuria, Spinal cord injury, Urinary tract infection.

Article

INTRODUCTION
Urinary tract infection (UTI) is the single most frequent, secondary medical complication in persons with spinal cord injury (SCI) who develop neurogenic bladder irrespective of the type of bladder management used1. UTIs affect the overall well being in these individuals contributing substantially to health care costs. Patients who have neurogenic bladder cannot have normal physiologic voiding and require catheterization for bladder drainage and prevention of urologic complications. Although renal failure is not the major problem at present, urinary tract infection still remains troublesome. When host defenses are seriously compromised by defective bladder emptying, presence of a urinary catheter, vesicoureteric reflux or stones then the individual is likely to be susceptible to virtually any organism that can invade the urinary tract2. Neurogenic bladder is at the risk of UTI for several reasons such as bladder distension and elevated detrusor pressure which cause loss of immunity and decreased wall movement of bladder3. Other predisposing factors include impaired bladder emptying, repeated instrumentation, vesiculoureteric reflux, and indwelling urinary catheters4. Bacteriuria is a problem almost universal in patients with vesico-sphincter dysfunction, and is often associated with the use of catheters as a method of bladder emptying5. The diagnosis of UTI is usually made based on the presence of signs and symptoms and confirmed by culture examination with significant bacteriuria supported by high level pyuria. Invariably neurogenic bladder is dependant on catheter indwelling or intermittent for drainage but indwelling urinary catheter is virtually always associated with bacteriuria with in a few days after it is inserted as a safe drainage method but Intermittent catheterization (IC) has become a mainstay in the care of patients with SCI who have adequate hand function or a willing health care provider. It is favored mainly because of evidence that it decreases the incidence of UTI and urologic complications6.
In addition to standard uncoated polyethylene catheters, the market today provides hydrophilic-coated catheters. It is hypothesized that the hydrophilic catheters may cause fewer UTIs than standard catheters7 However IC is safe midway option associated with fewer complication and UTI episodes. In most of the international studies predominant etiologic agent of UTI in SCI is E-coli followed by other enterobacters, such as Klebsiella pneumoniae and Proteus mirabilis8. Patients with SCI are also prone to the development of bladder and renal stones. One link between chronic bacteriuria and the formation of stones is infection of the urinary tract with urease-producing organisms including Klebsiella, Providencia, Morganella,, and Proteus. UTI in neurogenic bladder can result in epididymitis, orchitis, penoscrotal abscess, penoscrotal fistula bladder stones and cancers. This can also complicate upper urinary tract and result in pyelonephritis hydronephrosis, renal stones, renal scarring, renal function deterioration which can cause chronic renal failure9,10. Studying the local spectrum and sensitivity of causative organisms and characterizing safest mode of drainage will not only help in reducing the disease burden but also ensure prompt and early rehabilitation.
MATERIAL AND METHODS
This descriptive study was carried out at Armed Forces Institute of Rehabilitation Medicine (AFIRM) Rawalpindi from September 2007 to March 2008. A total of 100 patients with acute and chronic spinal cord injury were included.
Inclusion criteria
Male and female patients of all ages with acute or chronic spinal cord injury.
Exclusion criteria
Patients receiving any type of immunosuppressive therapy or suffering from immune deficiency disorder to avoid the bias of increased susceptibility of infection.
Data collection procedure
One hundred patients of spinal cord injury were included in the study, data was collected from each of the 100 SCI selected patients for a period of 6 months e.g occurrence of symptoms of urinary infection, and method of urinary drainage system including the actual procedure of urethral catheterization. Urine samples of all these patients were taken. A blood sample was sent for TLC count in each case. Method of collection of data was observational using TLC, urine RE and urine culture and sensitivity. UTI was defined to be present if the patients had sign and symptoms of UTI and urine culture revealed a bacterial colony count of 105 (cfu/ml of urine) or higher.
Statistics Analysis
All the data regarding demographical, clinical details, microbiological and biochemical parameters was registered and compiled for statistical analysis using SPSS version 10.0. Mean and SD was calculated for numerical variable i.e. age. Frequency and percentage were calculated for categorical variables i.e. gender, urine R/E, C/S and mode of voiding.
RESULTS
Of 100 spinal cord injured patients, there were 90 males and 10 females, with the age ranging from 12 to 67 yrs, with a mean age of 41.3 + 28.3 years. Fifty two patients (52%) had symptoms suggestive of UTI but only 37 patients (37%) had significant bacteriuria on urine culture supported by high level pyuria in routine urine examination, were declared to have UTI. Eleven (11%) had insignificant bactriuria and 52 (52%) showed no growth on urine culture. Of 37 patients with significant bacterial growth,

Escherichia coli was the most commonly isolated organism with total no of 20 cases (54.1%) followed by Pseudomonas aureginosa with 6 cases (16.2%), Klebsiella pneumoniae 3 cases(8.1%), Proteus mirabilis 3 cases (8.1%), Citrobacter freundii 2 cases (5.4%) Candida 2 cases (5.4%) and Morganella morganii 1 case (2.7%). (Table1).

Most gram-negative bacteria were susceptible to amikacin and third-generation cephalosporins Frequency of UTI was calculated in different modes of voiding urine and it was found that out of 37 patients with UTI 20 (54.05%) had indwelling catheter , 15 (40.5%) were using clean intermittent catheterization (IC), 1 (2.7% )was using crede maneuver to void urine, and 1 (2.7%) had suprapubic cystostomy, while no patients with reflex voiding and urinary continence had UTI, showing that, UTI was more frequent in SCI patients using catheterization as mode of voiding but more in indwelling catheterization as compared to IC, proving safety of use of IC in neurogenic bladder
DISCUSSION
The annual worldwide incidence of spinal cord injury (SCI) is approximately 40 per million. Asymptomatic bacteriuria is common (70%) in SCI patients under catheterization, with UTI the most frequent complication. Patients with SCI are also prone to the development of bladder and renal stones and cancers. It is still one of the leading causes of morbidity in SCI11,12. UTI is traditionally considered by the presence of 100,000 or more bacteria/ml in urine13. Because of loss of sensation, patients with SCIs do not have the common symptoms of urinary tract infection such as fre­quency, urgency, and dysuria. The clinical features of UTI may include fever, pyuria, and other ‘‘soft’’ symptoms and signs such as discomfort over the back or abdomen during urination, onset of incontinence, increased spasticity, autonomic hyper­reflexia, malaise, lethargy, or observation of cloudy urine with increased odor14. This study showed that in 100 SCI patients during a study period of 6 months, frequency of UTI was 37%. This result is consistent with other international studies, which also document a high frequency and prevalence of UTI in SCI patients. Siroky et al and Garcia et al revealed in their studies that UTI is a very common complication in persons with SCI15,16. Escherichia coli is generally considered to be the most common cause of UTI and Staphylococcus saprophyticus, Proteus mirabilis, Streptococcus agalactiae, and Klebsiella spp. are responsible for most of the remaining cases17. In contrast, complicated UTIs, in which a predisposing factor is present concomitantly, are caused by a much wider variety of organisms18. In this study as well it was seen that in our rehabilitation setup UTI is frequent in spinal cord injury patients and E.coli is the most common causative pathogen followed by Pseudomonas aureginosa, Klebsiella pneumoniae, Proteus mirabilis, Citrobacter freundi, Candida and Morganella morganii. Most gram-negative bacteria were susceptible to amikacin and third-generation cephalosporins ,these results are consistent with other international studies E. Hernández Fernández et al in his study19 reported that the etiologic agent predominant in UTI with SCI was E. coli, found in 60% of cases and followed by other organisms such as K. Pneumoniae and P. mirabilis mainly, there were not remarkable differences in uropathogens when it was compared with UTI but, without SCI as in other reports8. UTI was more frequent in patients using indwelling catheterization and CIC as method of bladder drainage, consistent with findings of another study in which it was found that patients who use CIC as drainage method still had an increase chance to develop UTI as compared to normal voiding but less than indwelling catheter20. The method of bladder management should be based on urodynamic evaluation and diagnosis of the type of bladder dysfunction21. CIC is usually the primary recommendation for long-term bladder management22. For practical reasons, reflex voiding and Crede or Valsalva methods are still commonly in use, often combined with condom drainage in men. CIC and reflex voiding may be used simultaneously. In addition, indwelling catheter (urethral or suprapubic) remain in common use23. Although both are associated with very high incidence of UTI caused by resistant organisms. Lack of pyuria reasonably predicts the absence of UTI in SCI patients. Asymptomatic bacteriuria need not be treated with antibiotics. Symptomatic UTI warrants therapy in all patients24. Asymptomatic bacteriuria (ASB), incontinence, impaired bladder emptying, repeated instrumentation, vesiculoureteral reflux, indwelling urinary catheters, elevated intravesical pressure, stones, and neurological obstruction25 are also prevalent in patients with SCI. Since chronic and recurrent infection is more prevalent in SCI patients we need to have knowledge of local bacterial spectrum and sensitivity to device empirical antibiotic therapy to start the treatment before the results of urine C/S is available to shorten treatment time and cost. There is no doubt that the greatest risk for complicated UTI in these individuals is the use of an indwelling catheter. Intermittent catheterization during the rehabilitation phase has been shown to lower the rate of UTI, and virtually eliminate many of the complications associated with indwelling catheters. If the patient has a reinfection or relapsing symptomatic UTI, it is important to check for inadequately treated infection and complications, in particular residual urine and urinary stones. No reliable evidence exists of the effectiveness of cranberry juice, topical antiseptic agents and catheter flushing. Prophylactic antibacterial should only be used in patients with recurrent UTI where no underlying cause can be found and managed, and in particular if the upper urinary tract is dilated.
CONCLUSION
Urinary tract infections were commonly observed among spinal cord injured patients in the presented institution. E-coli were the commonest isolated pathogen followed by Pseudomonas, Klebsiella pneumoniae, Proteus mirabilis, Citrobacter freundi, Candida and Morganella morganii. UTI was more frequent in SCI patients using catheterization as mode of voiding but more in indwelling catheterization as compared to IC, supporting use of IC in neurogenic bladder.

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