Tract Infections after SCI
Urinary Tract Infections (UTIs)
have always been a major concern for individuals with spinal cord injury (SCI).
Before WW II, almost all persons with SCI died from complications related to UTI.
- 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 UTIs
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
- 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
a urine sample is taken from a patient with an indwelling catheter, any
bacteria detected is a significant finding for infection
Between 10 and 20% of patients
who are hospitalized receive an indwelling foley catheter. Once this catheter
is in place, the risk of bacteriuria is approximately 5% per day. With long-term
catheterization, bacteriuria is inevitable. Catheter-associated UTIs account for
40% of all nosocomial infections and are the most common source of gram-negative
bacteremia in hospitalized patients.
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,
- 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)
- 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
- 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
- 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.
101) usually accompanies a lower urinary tract infection in patients with spinal
Some additional points to consider:
- 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.
- 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
- Try different
products or systems
Guideline for Prevention of Catheter-associated Urinary Tract Infections
is an excellent resource.
information about UTIs, the American
Family Physician website has an excellent resource entitled Urinary
Tract Infections in Adults.
urine culture should be repeated if it comes back with more than two organisms.