Today:

• UTIs are the #1 medical complication for individuals with SCI.
• UTIs are more likely to affect the overall health and health care costs of individuals with SCI than any other single complication.
• Costs to treat UTI’s are exponentially higher than the costs to prevent them.

What are some of the causes of UTIs among individuals with SCI?

• Bacteria from skin and the urethra are easily brought into the bladder with intermittent catheterization (ICs), foley catheters and suprapubic methods of bladder management.
• Clients may not practice proper technique. For example, they may not use proper handwashing, or disinfect the catheter.
• Bacteria may remain in the bladder because the bladder may not be completely emptied.
  

There is some controversy about the true definition of a UTI. Traditionally, a UTI was diagnosed if more than 100,000 organisms were cultured from one ml of urine (AKA >100,000 coliforms/ml or CFU). However, studies have shown acutely symptomatic infections in able-bodied (or normally healthy) patients with cultures as low as 200 CFU!

The consensus of the National Institute on Disability and Rehabilitation (NIDRR), is that the method of urine collection affects how much bacteria is significant for patients with SCI:

• For patients on intermittent catheterization, more than 100 CFU/ml is significant
• For non-catheterized specimens, more than 10,000 CFU/ml is significant
• For patients with an indwelling catheter ANY detectable bacteria is significant

Signs and symptoms of a UTI involving the lower urinary tract may include:

• dysuria (extraordinary pain or burning on urination), frequency, urinary incontinence, and hematuria.

Unless a patient has had acute retention or urologic instrumentation, fever is not likely when the lower urinary tract is involved. Since many patients with SCI have decreased or no bladder sensation, it's important to also look for other signs of a lower UTI, such as:

• cloudy, strong smelling urine, increased abdominal or lower extremity spasticity, new onset of urinary incontinence, occasionally retention from increased DSD, or autonomic dysreflexia in those with a lesion above T6.

Patients with acute upper urinary tract involvement may present with any of the above signs and symptoms, as well as:

• fever (temperature 101 degrees F or greater)
• chills
• nausea
• headache
• elevated serum white blood cell count

Those with sensation usually complain of costal vertebral angle (CVA) tenderness. In the elderly, these signs may be subtler, and may include confusion and lethargy.

UTIs are managed with a combination of antibiotics, improved bladder management and prevention methods.

There is general agreement that asymptomatic bacteriuria in a patient with an indwelling foley catheter should NOT be treated. An exception is made, however, if instrumentation is to be performed. Prophylactic antibiotics should be considered in patients with asymptomatic bacteriuria, especially when patients have reflux problems.

For patients that are mildly symptomatic, once a urine culture is obtained, oral antibiotics should be started while waiting for the results of the culture. Generally, a 7-day course is preferable. The urine culture and sensitivity ("C & S") will determine what organism is growing and what antibiotics will effectively treat it.

For patients with high fevers, dehydration, or autonomic dysreflexia, more aggressive therapy should be instituted.

• Patients should be hospitalized, closely monitored, hydrated, and given broad spectrum antibiotics (gentamicin and ampicillin) while waiting for the culture results and the fever to go down.
• It is important to have an indwelling catheter in place during IV or oral fluid hydration to keep the bladder decompressed.
• An anticholinergic medication may also be beneficial while the catheter is in place. The medication will decrease the intrinsic pressure within the bladder, improving drainage of the kidneys.
• Patient with significant fevers should be considered to have upper tract involvement (pyelonephritis) and therefore should continue receiving oral antibiotics for 2 to 3 weeks after the fever has resolved.
  • In addition, these patients should undergo a urologic evaluation for the cause of urosepsis. During the acute phase, a plain abdominal Xray is sufficient to rule out an obvious stone, but then should be followed by a renal ultrasound. If there is a question of a stone, hydronephrosis or persistent fever, an IVP should be performed. Once the initial treatment has taken place, it is often necessary to perform a cystogram to evaluate for reflux, a cystoscopy to evaluate the bladder outlet, and bladder and urodynamic testing to evaluate voiding function.

• If the culture comes back with more than two organisms, the culture needs to be repeated. It is very possible that the sample was contaminated.
• It is important to note that the client may eventually grow resistant to the antibiotic(s). The problem with frequent UTIs is an increased need for treatment with antibiotics. Eventually, the client will be infected with an antibiotic-resistant bacterium.
  • The U.S. Food and Drug Administration website's video on Antimicrobial Resistance video may be a useful patient education resource.
• In the case of a patient that has preserved sensations, or is self-voiding, with "irritative" voiding symptoms, urgency, diurnal frequency, or dysuria, the patient should be advised to limit caffeine intake.
• Current prevention and treatment programs make UTIs more manageable, but many could be avoided with proper bladder programs. The majority of UTIs are preventable. Prevention of UTIs is the KEY to avoiding bladder management complications. Above all, training and education of the NEWLY injured patient is paramount.
  • For example, the following fundamentals of infection prevention are always appropriate to teach and learn.
    
    • Wash hands
    • Increase fluid intake (water or cranberry juice/tablets)
    • Maintain supplies properly
    • Try different products or systems

The CDC Guideline for Prevention of Catheter-associated Urinary Tract Infections is an excellent resource.

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