A quantitative study of genital skin flora and urinary colonization in spinal cord injured patients

Epidemiology of Hospital-Acquired Infections in Veterans With Spinal Cord Injury and Disorder

Objective.

To describe the epidemiology of hospital-acquired infections (HAIs) in veterans with spinal cord injury and disorder (SCI&D).

Design.

Retrospective medical record review.

Setting.

Midwestern Department of Veterans Affairs spinal cord injury center.

Participants.

A total of 226 patients with SCI&D hospitalized at least once during a 2-year period (October 1, 2001, through September 30, 2003).

Results.

A total of 549 hospitalizations were included in the analysis (mean duration of hospitalization, 33.7 days); an HAI occurred during 182 (33.2%) of these hospitalizations. A total of 657 HAIs occurred during 18,517 patient-days in the hospital (incidence rate, 35.5 HAIs per 1,000 patient-days). Almost half of the 226 patients had at least 1 HAI; the mean number of HAIs among these patients was 6.0 HAIs per patient. The most common HAIs were urinary tract infection (164 [25.0%] of the 657 HAIs; incidence rate, 8.9 cases per 1,000 patient-days), bloodstream infection (111 [16.9%]; incidence rate, 6.0 cases per 1,000 patient-days), and bone and joint infection (103 [15.7%]; incidence rate, 5.6 cases per 1,000 patient-days). The most common culture isolates were gram-positive bacteria (1,082 [45.6%] of 2,307 isolates), including Staphylococcus aureus, and gram-negative bacteria (1,033 [43.6%] of isolates), including Pseudomonas aeruginosa. Multivariate regression demonstrated that predictors of HAI were longer length of hospital stay (P = .002), community-acquired infection (P = .007), and use of a urinary invasive device (P = .01) or respiratory invasive device (P = .04).

Conclusions.

The overall incidence of HAIs in persons with SCI&D was higher than that reported for other populations, confirming the increased risk of HAI in persons with spinal cord injury. The increased risk associated with longer length of stay and with community-acquired infection suggests that strategies are needed to reduce the duration of hospitalization and to effectively treat community-acquired infection, to decrease infection rates. There is significant room for improvement in reducing the incidence of HAIs in this population.

Urinary tract infections in spinal cord injury: prevention and treatment guidelines

OBJECTIVES AND METHODS

The literature on prevention and therapy of urinary tract infection (UTI) in patients with spinal cord injury (SCI) was reviewed using 3 levels of evidence.

RESULTS

Antibiotic therapy is only indicated in symptomatic bacteriuria or in symptomatic exacerbations of chronic UTI. During the acute phase of a SCI, UTI's are more prevalent and bacteria are different and more resistant to antibiotics compared with the chronic phase of SCI. In SCI in general, routine screening urine cultures are not valuable as a high species turn over is seen. Intermittent catheterisation, tapping or Crédé manoeuvre coincide significantly with lower frequency of UTI compared to permanent catheter drainage. No measures are proven efficient in the long term in prevention of bacteriuria or UTI. Methenamine salts are perhaps useful in the prevention of UTI but not in patients with a permanent catheter (level III). Antibiotic prophylaxis was found useful in reducing asymptomatic bacteriuria but not in the prevention of symptomatic infections (level I). However, during prophylaxis a doubling of antibiotic resistance was found. In patients with augmented bladder antibiotic prophylaxis is useless (level II). In chronic SCI the first choice antibiotics are nitrofurantoin or trimethoprim, the second choice are fluoroquinolones (level III) whereas in acute SCI a higher resistance profile to antibiotics is frequent and therefore fluoroquinolones or cefuroxime are suggested (level III). There is no consensus in the literature but we suggest 5 days of antibiotic treatment in UTI during chronic SCI without fever, 7 days in acute SCI without fever and a minimum of 14 days in patients with UTI and fever (level III).

Significant upregulation of antimicrobial peptides and proteins in lichen sclerosus

BACKGROUND

Lichen sclerosus (LS) is a chronic inflammatory T cell-driven sclerotic skin condition in which skin barrier disruption frequently occurs. Inflamed and injured epithelia are a particularly rich source of antimicrobial peptides and proteins (AMPs).

OBJECTIVES

We aimed to investigate for the first time the expression pattern of AMPs in lesions of LS as compared with healthy skin.

METHODS

Twenty-four women with LS as well as 10 healthy women were included in the study. In order to assess the expression of human beta-defensin (hBD)-1, hBD-2, hBD-3, psoriasin (S100A7), the cathelicidin LL-37 and RNase 7, real-time reverse transcriptase-polymerase chain reaction and immunohistochemistry were performed on skin specimens obtained from lesional and healthy skin of the genital region, respectively.

RESULTS

Median hBD-2 mRNA levels observed in LS were significantly higher than in controls (0.15 vs. 0.008; P = 0.0037). Moreover, psoriasin (98.2 vs. 28.1; P = 0.0052) mRNA expression was significantly higher in LS lesions as compared with controls. Significant differences in mRNA expression of hBD-2 and psoriasin were also confirmed by immunohistochemistry. For hBD-1, hBD-3, LL-37 and RNase 7, levels did not differ significantly or were significant only at the gene level but not protein level.

CONCLUSIONS

We have demonstrated that hBD-2 and psoriasin expression levels in lesional skin of patients with LS are significantly increased when compared with healthy controls. Whether this observation simply reflects an innate defence response caused by an increased risk of local infection, or whether our data indicate a pathogenetic role of AMPs in LS, will be addressed in future studies.

Urethral cultures in patients with spinal cord injury

STUDY DESIGN

Prospective analysis.

OBJECTIVES

To investigate the colonization of the distal urethra and bladder during the initial stages of rehabilitation in acute spinal-cord injury (SCI) and to examine the association between bacteriuria and colonization of the distal urethra.

SETTING

Selcuk University Meram Faculty of Medicine, Konya, Turkey.

METHODS

A total of 27 patients with SCI (13 females and 14 males) and 40 controls without evidence of disease of the urinary tract were studied. Cultures were taken from the patients who applied clean intermittent catheterization and compared with normal subjects.

RESULTS

Escherichia coli was predominantly isolated from the urine and urethral cultures of both female and male SCI patients. Colonization of other bacteria in the urine and urethral cultures was similar in both female and male patients, except for Pseudomonas, which was colonized in male patients. In all, 72% of patients who had E. coli positive urethral cultures also had E. coli colonization in their simultaneous urine cultures. There was concordance between urethra and urine cultures concerning the growth of E. coli (P=0.82). When urethral cultures collected 1 week before were evaluated in patients with E. coli positive urine cultures (n=24 cultures), 15 of these urethral cultures also had E. coli colonization. There was concordance between urethra and urine cultures concerning the growth of E. coli (P=0.66).

CONCLUSIONS

Our study suggested that urethral flora was a significant source for the development of urinary infection in spinal cord-injured patients.

Pathogenesis of bacteriuria and infection in the spinal cord injured patient

Spinal cord injury (SCI) produces profound alterations in lower urinary tract function. Incontinence, elevated intravesical pressure, reflux, stones, and neurological obstruction, commonly found in the spinal cord-injured population, increase the risk of urinary infection. The overall rate of urinary infection in SCI patient is about 2.5 episodes per patient per year. Despite improved methods of treatment, urinary tract morbidity still ranks as the second leading cause of death in the SCI patient.SCI removes the ability of the pontine micturition center and higher centers in the brain to inhibit, control, or coordinate the activity of the vesicourethral unit. As a result, a patient with complete quadriplegia is typically unaware of bladder activity. Bladder contraction is accompanied by vesicosphincter dyssynergia instead of sphincter relaxation. It is widely accepted that intermittent catheterization, when compared with indwelling catheters, reduces the risk of urinary tract infection (UTI) in SCI patients and is the preferred method of bladder drainage in this patient population. Attempts at eliminating bacteriuria associated with indwelling or intermittent catheters have generally been unsuccessful. There is now appreciation of the fact that a creeping adherent biofilm of bacteria frequently ascends through the luminal and external surfaces of an indwelling catheter, often within 8 to 24 hours, leading to bacterial adherence to the bladder surface and correlating with symptomatic infection. The use of antimicrobial agents to clear or prevent bacteriuria in patients on indwelling or intermittent catheterization has had mixed success. Treatment for asymptomatic bacteriuria in SCI patients remains controversial. SCI patients with symptomatic urinary infections should be treated with the most specific, narrowest spectrum antibiotics available for the shortest possible time. Guidelines for selecting antimicrobial agents in SCI patients are similar to guidelines for the treatment of complicated urinary infections in the general population. Characteristics of the quinolones make them well suited to treating UTI in the SCI patient.

Urinary tract infection in patients with neurogenic bladder dysfunction

Recurrent urinary tract infections (UTI) are a significant problem in all patients with neurogenic bladder leading to high morbidity, poor quality of life and a limited life expectancy. For the diagnosis of UTI, a urine specimen taken by bladder puncture or catheterization is required. In patients with neurogenic bladders, clinical symptoms and leukocyturia must be present together with bacteriuria in order to qualify as UTI. The spectrum of pathogens differs significantly from that in patients with normal bladder function. Culture and antimicrobial susceptibility testing must, therefore, be performed prior to the initiation of antibiotic therapy. This is also important in the prevention of the emergence of antimicrobial resistance. The main way to prevent recurrent UTI in the neurogenic bladder is by restoring the normal low-pressure reservoir function of the bladder and is the aim of neuro-urological management.