Significance of bacteriuria in neurogenic bladder

Urinary Symptoms Among People With Neurogenic Lower Urinary Tract Dysfunction (NLUTD) Vary by Bladder Management

Objectives

To determine whether assessment and decision-making around urinary symptoms in people with neurogenic lower urinary tract dysfunction (NLUTD) should depend on bladder management.

Methods

Three surveys of urinary symptoms associated with NLUTD (USQNBs) were designed specific to bladder management method for those who manage their bladders with indwelling catheter (IDC), intermittent catheter (IC), or voiding (V). Each was deployed one time to a national sample. Subject matter experts qualitatively assessed the wording of validated items to identify potential duplicates. Clustering by unsupervised structural learning was used to analyze duplicates. Each item was classified into mutually exclusive and exhaustive categories: clinically actionable ("fever"), bladder-specific ("suprapubic pain"), urine quality ("cloudy urine"), or constitutional ("leg pain").

Results

A core of 10 "NLUTD urinary symptoms" contains three clinically actionable, bladder-specific, and urine quality items plus one constitutional item. There are 9 (IDC), 11 (IC), and 8 (V) items unique to these instruments. One decision-making protocol applies to all instruments.

Conclusion

Ten urinary symptoms in NLUTD are independent of bladder management, whereas a similar number depend on bladder management. We conclude that assessment of urinary symptoms for persons with NLUTD should be specific to bladder management method, like the USQNBs are.

Development and Assessment of SCI Model Systems Complicated UTI Consensus Guidelines: A Psychometrically Designed Mixed-Methods Protocol

Background

Complicated UTI (cUTI) is highly prevalent among people with spinal cord injury and disease (SCI/D), but neither consistent nor evidence-based guidelines exist.

Objectives

We propose a two-phase, mixed-methods study to develop consensus around diagnostic and decision-making criteria for cUTI among people with SCI/D and the clinicians who treat them.

Methods

In phase 1 (qualitative), we will engage Spinal Cord Injury Model Systems (SCIMS) clinicians in focus groups to refine existing cUTI-related decision making using three reliable and validated Urinary Symptom Questionnaires for Neurogenic Bladder (USQNBs; intermittent catheterization, indwelling catheterization, and voiding) as points of departure, and then we will conduct a Delphi survey to explore and achieve consensus on cUTI diagnostic criteria among a nationally representative sample of clinicians from physical medicine and rehabilitation, infectious disease, urology, primary care, and emergency medicine. We will develop training materials based on these new guidelines and will deploy the training to both clinicians and consumers nationally. In phase 2 (quantitative), we will assess clinicians' uptake and use of the guidelines, and the impact of the guidelines training on consumers' self-management habits, engagement with the health care system, and antibiotic use over the 12 months after training.

Results

The output of this study will be diagnostic guidelines for cUTI among people with neurogenic lower urinary tract dysfunction (NLUTD) due to SCI/D, with data on uptake (clinicians) and impact (patients).

Conclusion

This mixed-methods protocol integrates formal psychometric methods with large-scale evidence gathering to derive consensus around diagnostic guidelines for cUTI among people with NLUTD due to SCI/D and provides information on uptake (clinicians) and impact (patients).

Effects of Intravesical Lactobacillus Rhamnosus GG on Urinary Symptom Burden in People with Neurogenic Lower Urinary Tract Dysfunction

OBJECTIVE

To test the effectiveness of intravesical Lactobacillus rhamnosus GG (LGG) to reduce the burden of urinary symptoms for individuals with spinal cord injury and disease (SCI/D) with neurogenic lower urinary tract dysfunction (NLUTD) who manage their bladders with intermittent catheterization (IC).

DESIGN

A three-phase study (6 months each in baseline, intervention, and washout). Participants self-managed following the Self-Management Protocol using Probiotics (SMP-Pro), completing the online Urinary Symptom Questionnaire for Neurogenic Bladder-IC version (USQNB-IC) weekly.

SETTING

Nationwide (United States).

PARTICIPANTS

Ninety-six adults and seven children with SCI/D.

INTERVENTIONS

In response to one or both of the SMP-Pro trigger urinary symptoms, "cloudier" or "foul smelling" urine, participants self-administered using a clean urinary catheter an LGG+ Normal Saline instillate once or twice in a 30-hour period.

MAIN OUTCOME MEASURES

Change in USQNB-IC burden was adjusted individually according to the previous phase for four symptom types. Adjusted changes in burden between the intervention and washout phases were analyzed using one-sample t-tests. Holm correction was applied for the four types of symptoms: A, clinically actionable; B1, bladder function; B2, urine quality; and C, other.

RESULTS

During the intervention phase, participants met SMP-Pro instillation criteria 3.83 times on average (range 1-20). An average of 5.6 doses of LGG were instilled. For those who instilled at least once, burdens of type A and B2 symptoms were significantly improved at washout (both adjusted P < .05).

CONCLUSIONS

Self-instilled LGG seemed to improve "clinically actionable" (A) and "urine quality" (B2) symptom burden. No changes were observed for those who did not instill. This first-in-human clinical trial supports ongoing research of intravesical LGG, and the SMP-Pro for urinary symptoms.

Urinary tract infections in patients with neurogenic bladder

Urinary tract infections (UTIs) in patients with neurogenic bladder are a major public health issue due to their high incidence and major consequences. Despite their frequency and potential severity, their physiopathology and management are poorly known. We provide a narrative literature review on the epidemiology, physiopathology, diagnostic criteria, microbiology, antimicrobial management, and prevention. UTIs among patients with neurogenic bladder are associated with high morbidity and healthcare utilization. Risk factors for UTI among this population are: indwelling catheter, urinary stasis, high bladder pressure, and bladder stones. Their diagnosis is a major challenge as clinical signs are often non-specific and rare. A urinary sample should be analyzed in appropriate conditions before any antibiotic prescription. According to most guidelines, a bacterial threshold≥103CFU/ml associated with symptoms is acceptable to define UTI in patients with neurogenic bladder. The management of acute symptomatic UTI is not evidence-based. A management with a single agent and a short antibiotic treatment of 10 days or less seems effective. Antibiotic selection should be based on the patient's resistance patterns. Asymptomatic bacteriuria should not be treated to avoid the emergence of bacterial resistance. Regarding preventive measures, use of clean intermittent catheterization, intravesical botulinum toxin injection, and prevention using antibiotic cycling are effective. Bacterial interference is promising but randomized controlled trials are needed. Large ongoing cohorts and randomized controlled trials should soon provide more evidence-based data.

Intravesical Lactobacillus rhamnosus GG is safe and well tolerated in adults and children with neurogenic lower urinary tract dysfunction: first-in-human trial

BACKGROUND

Urinary symptoms are common for people with neurogenic lower urinary tract dysfunction (NLUTD). No nonprescription approach has been proven safe and effective for self-management of urinary symptoms. Our objective was to describe the safety and tolerability of Lactobacillus rhamnosus GG (LGG®) instilled intravesically for self-management of inflammatory urinary symptoms in adults and children with NLUTD due to spinal cord injury or disease (SCI/D) and who use intermittent catheterization (IC).

METHODS

A total of 103 individuals with SCI/D enrolled in an 18-month study consisting of three 6-month stages: baseline (weekly observation of urinary symptoms); intervention (self-instilled intravesical LGG® in response to more cloudy or foul-smelling urine); and washout (weekly observation of urinary symptoms). Urinary symptoms were assessed using the Urinary Symptom Questionnaire for people with neurogenic bladder using intermittent catheters (USQNB-IC). Safety was based on serious adverse events and adverse events (S/AEs) and trends in symptoms. Tolerability was defined as the independence of AE experience and willingness to use/pay for this intervention.

RESULTS

A total of 74 (77%) adults and 6 (86%) of children completed the study, of whom 64 instilled LGG® for a total of 357 instillations (range 1-41 per person). There were 59 S/AEs, 44% (26/59) of which were categorized as infectious genitourinary. There was no statistical relationship between S/AEs and use or dose of the intervention.

CONCLUSIONS

One or two doses of self-instilled intravesical LGG® in response to more cloudy or foul-smelling urine was safe and well tolerated among this sample of adults and children with SCI/D who have NLUTD and use IC.

Utility of a routine urinalysis in children who require clean intermittent catheterization

BACKGROUND

Children who require clean intermittent catheterization (CIC) frequently have positive urine cultures. However, diagnosing a urinary tract infection (UTI) can be difficult, as there are no standardized criteria. Routine urinalysis (UA) has good predictive accuracy for UTI in the general pediatric population, but data are limited on the utility of routine UA in the population of children who require CIC.

OBJECTIVE

To determine the utility of UA parameters (e.g. leukocyte esterase, nitrites, and pyuria) to predict UTI in children who require CIC, and identify a composite UA that has maximal predictive accuracy for UTI.

METHODS

A cross-sectional study of 133 children who required CIC, and had a UA and urine culture sent as part of standard of care. Patients in the no-UTI group all had UA and urine cultures sent as part of routine urodynamics, and were asymptomatic. Patients included in the UTI group had growth of ≥50,000 colony-forming units/ml of a known uropathogen on urine culture, in addition to two or more of the following symptoms: fever, abdominal pain, back pain, foul-smelling urine, new or worse incontinence, and pain with catheterization. Categorical data were compared using Chi-squared test, and continuous data were compared with Student's t-test. Sensitivity, specificity, and positive and negative predictive values were calculated for individual UA parameters, as well as the composite UA. Logistic regression was performed on potential composite UA models to identify the model that best fit the data.

RESULTS

There was a higher proportion of patients in the no-UTI group with negative leukocyte esterase compared with the UTI group. There was a higher proportion of patients with UTI who had large leukocyte esterase and positive nitrites compared with the no-UTI group (Summary Figure). There was no between-group difference in urinary white blood cells. Positive nitrites were the most specific (84.4%) for UTI. None of the parameters had a high positive predictive value, while all had high negative predictive values. The composite model with the best Akaike information criterion was >10 urinary white blood cells and either moderate or large leukocyte esterase, which had a positive predictive value of 33.3 and a negative predictive value of 90.4.

CONCLUSION

Routine UA had limited sensitivity, but moderate specificity, in predicting UTI in children who required CIC. The composite UA and moderate or large leukocyte esterase both had good negative predictive values for the outcome of UTI.

Validity of urine dipstick test to assess eradication of urinary tract infection in persons with spinal cord injury

OBJECTIVES

To prospectively study the predictive value (PV) of urine nitrite (NIT) dipstick testing against urine cultures during antibiotic treatment for urinary tract infection (UTI), and other situations, in patients with spinal cord injury (SCI).

METHODS

Inpatients with SCI on intermittent catheterisation (IC) or a Foley indwelling catheter (FC) were included. Urine specimens were collected in patients without symptoms (routine), with symptoms of UTI (suspicion), and on day 4 of a 5-day antibiotic treatment (ATB+3).

RESULTS

A total of 157 urine samples were collected in 61 patients: 34 were on IC (95 samples) and 27 on FC (62 samples). The prevalence of asymptomatic bacteriuria in the urine cultures was 89% in routine (70 samples). At ATB+3, microbiological cure was found in 27/30 specimens (IC group) and 2/6 (FC group). In the routine condition, the specificity and positive PV of the NIT tests was 1.00 and sensitivity 0.63. The negative PV was low in both groups. In suspicion of UTI, the sensitivity was between 0.69 and 0.55, the positive PV was 1.00 and the negative PV 0.00 for both groups. At ATB+3, the negative PV and sensitivity was 1.00, specificity 0.85 and positive PV 0.43 in the IC group, and in the FC group, specificity was 1.00, negative PV 0.33 and sensitivity 0.00.

CONCLUSION

In the SCI population on intermittent or indwelling catheters with high prevalence of bacteriuria, dipstick testing helped assess the eradication of germs during antibiotic treatment, but showed no value in the decision making process for UTI.

LEVEL OF EVIDENCE

3.

New and developing diagnostic technologies for urinary tract infections

Timely and accurate identification and determination of the antimicrobial susceptibility of uropathogens is central to the management of UTIs. Urine dipsticks are fast and amenable to point-of-care testing, but do not have adequate diagnostic accuracy or provide microbiological diagnosis. Urine culture with antimicrobial susceptibility testing takes 2-3 days and requires a clinical laboratory. The common use of empirical antibiotics has contributed to the rise of multidrug-resistant organisms, reducing treatment options and increasing costs. In addition to improved antimicrobial stewardship and the development of new antimicrobials, novel diagnostics are needed for timely microbial identification and determination of antimicrobial susceptibilities. New diagnostic platforms, including nucleic acid tests and mass spectrometry, have been approved for clinical use and have improved the speed and accuracy of pathogen identification from primary cultures. Optimization for direct urine testing would reduce the time to diagnosis, yet these technologies do not provide comprehensive information on antimicrobial susceptibility. Emerging technologies including biosensors, microfluidics, and other integrated platforms could improve UTI diagnosis via direct pathogen detection from urine samples, rapid antimicrobial susceptibility testing, and point-of-care testing. Successful development and implementation of these technologies has the potential to usher in an era of precision medicine to improve patient care and public health.

Infections in the spinal cord-injured population: a systematic review

STUDY DESIGN

Spinal cord injury (SCI) patients are an increasing population due to recent military conflicts. SCI patients are at an increased risk of infection, but the epidemiology management and prevention strategies for these infections are unclear.

OBJECTIVE

To review the incidence, microbiology and management of pneumonia, skin and soft tissue infections (SSTI), urinary tract infections (UTI) and bloodstream infections in the SCI population via literature review.

METHODS

With the assistance of an experienced medical librarian, we developed a search strategy for the Ovid MEDLINE database and then adapted it for the Ovid Embase, Scopus and Web of Science databases. The databases were searched from their inception to April 2014 with no restrictions on language or time period. Data were extracted using a standardized form. All studies were reviewed by two independent investigators.

RESULTS

Forty-one studies reporting on the described infections were identified. UTIs were the most commonly identified infections, but studies failed to identify consistently effective preventive strategies. SSTIs were also common, and the best preventive strategies focused on decubitus ulcer prevention and skin decolonization protocols. Pneumonia management and course were not significantly different from the general population. Bloodstream infections were associated with delays in recognition, and were most often secondary to UTI, pneumonia or SSTI.

CONCLUSION

There is a paucity of literature on consistently effective infection prevention strategies in SCI patients. Identification and implementation of evidence-based interventions that optimize prevention and management of infections in this patient population are needed.

Perioperative Cefovecin to Reduce the Incidence of Urinary Tract Infection in Dogs Undergoing Hemilaminectomy

The prevalence of urinary tract infections (UTIs) in dogs with Type I intervertebral disc extrusion has been reported as high as 38% within 6 wk of surgery. Proper treatment of a UTI is important with myelopathy because it is a risk factor for persistent infection and reinfection in dogs. The study authors' investigated the incidence of UTIs in dogs having received either cefovecin or cefazolin as a preoperative prophylactic antibiotic for thoracolumbar hemilaminectomy. Thirty-nine dogs were retrospectively identified and assigned to groups based on preoperative antibiotic administration and postoperative urinary tract management. Urinalysis and urine culture performed preoperatively, at 2 wk, and at 6 wk, were reviewed to determine the incidence of UTIs. Urinary tract management, grade of neurologic deficit, time to ambulation, and time to voluntary urination were identified to evaluate for additional risk factors. No significant prevalence of UTI incidence was appreciated between the cefovecin and cefazolin groups. Patients with higher grades of neurologic deficit and that took longer to regain ambulation and voluntary urination were at significantly greater risk for UTIs throughout the postoperative period. This study reemphasizes the importance of continued surveillance for UTIs in patients with prolonged neurologic recovery.

Urinary tract infection in the neurogenic bladder

There is a high incidence of urinary tract infection (UTI) in patients with neurogenic lower urinary tract function. This results in significant morbidity and health care utilization. Multiple well-established risk factors unique to a neurogenic bladder (NB) exist while others require ongoing investigation. It is important for care providers to have a good understanding of the different structural, physiological, immunological and catheter-related risk factors so that they may be modified when possible. Diagnosis remains complicated. Appropriate specimen collection is of paramount importance and a UTI cannot be diagnosed based on urinalysis or clinical presentation alone. A culture result with a bacterial concentration of ≥10(3) CFU/mL in combination with symptoms represents an acceptable definition for UTI diagnosis in NB patients. Cystoscopy, ultrasound and urodynamics should be utilized for the evaluation of recurrent infections in NB patients. An acute, symptomatic UTI should be treated with antibiotics for 5-14 days depending on the severity of the presentation. Antibiotic selection should be based on local and patient-based resistance patterns and the spectrum should be as narrow as possible if there are no concerns regarding urosepsis. Asymptomatic bacteriuria (AB) should not be treated because of rising resistance patterns and lack of clinical efficacy. The most important preventative measures include closed catheter drainage in patients with an indwelling catheter and the use of clean intermittent catheterization (CIC) over other methods of bladder management if possible. The use of hydrophilic or impregnated catheters is not recommended. Intravesical Botox, bacterial interference and sacral neuromodulation show significant promise for the prevention of UTIs in higher risk NB patients and future, multi-center, randomized controlled trials are required.

Retrospective study for risk factors for febrile UTI in spinal cord injury patients with routine concomitant intermittent catheterization in outpatient settings

STUDY DESIGN

Retrospective study.

OBJECTIVES

The objective of this study was to investigate the clinical risk factors for febrile urinary tract infection (UTI) in spinal cord injury-associated neurogenic bladder (NB) patients who perform routine clean intermittent catheterization (CIC).

SETTING

Rehabilitation Hospital, Kobe, Japan.

METHODS

Over a 3-year period, we retrospectively assessed the clinical risk factors for febrile UTI in 259 spinal cord injury patients diagnosed as NB and performing routine CIC with regard to the factors such as gender, the presence of pyuria and bacteriuria, and the categories of the American Spinal Injury Association (ASIA) impairment scale.

RESULTS

A total of 67 patients had febrile UTI in the follow-up period, with 57 cases of pyelonephritis, 11 cases of epididymitis and 2 cases of prostatitis, including the patients with plural infectious diseases. The causative bacteria were ranked as follows: Escherichia coli (74 cases), Pseudomonas aeruginosa (17 cases), Enterococcus faecalis (14 cases) and Klebsiella pneumoniae (12 cases). Antibiotic-resistant E. coli were seen, with 10.5% instances of extended-spectrum β-lactamase (ESBL) production and 23.8% of fluoroquinolone resistance. Multivariate analyses of clinical risk factors for febrile UTI showed that gender (male, P=0.0431), and ASIA impairment scale C or more severe (P=0.0266) were significantly associated with febrile UTI occurrence in NB patients with routine CIC.

CONCLUSION

Our data demonstrated gender (male) and ASIA impairment scale C or more severe were significantly associated with febrile UTI occurrence in NB patients using routine CIC. Further prospective studies are necessary to define the full spectrum of possible risk factors for febrile UTI in these patients.

Are prophylactic antibiotics necessary for urodynamic study?

The aim of this study was to assess the efficacy of prophylactic fosfomycin tromethamine (FT) and ciprofloxacin in preventing bacteriuria caused by urodynamic studies (UDS). A total of 426 adult patients presenting for UDS were enrolled the study. A midstream urine sample was taken 72 hours before and 5 days after the procedure. All patients underwent a standard UDS. The 411 patients who had sterile urine before intervention were included in the study. Patients were randomized into three groups. Group1 received no prophylaxis (n = 133), Group 2 (n = 141) received oral ciprofloxacin (500 mg) 1 hour before the procedure, and Group 3 (n = 137) received a single dose of FT approximately 12 hours before the procedure. Bacteriuria was evaluated for each group. Bacteriuria was detected in 3 (2.3%), 6 (4.3%) and 3 patients (1.6%) in Group 1, Group 2, and Group 3, respectively. The most common identified microorganism was Escherichia coli (E coli) in 6 patients (50%). Among the E coli group, extended spectrum beta-lactamase producing E coli was seen in 2 patients (33.3%). Univariate analysis demonstrated that a history of urogenital operation (p < 0.01) and female gender (p < 0.01) were significant risk factors for bacteriuria. On multiple logistic regression analysis, the past urogenital operation history was the only significant independent risk factor for significant bacteriuria after UDS (OR = 14, 95% CI = 1.82-23.8, p = 0.01). The prevalence of bacteriuria after UDS was relatively low in the current study population. Therefore, for most patients, it may be unnecessary to use preventive prophylactic antibiotics. However, our results suggest that in patients with a previous history of urologic surgery, the risk for significant bacteriuria is increased and the use of prophylaxis should be considered.

Prophylactic antibiotics to reduce the risk of urinary tract infections after urodynamic studies

BACKGROUND

There is a risk that people who have invasive urodynamic studies (cystometry) will develop urinary tract infections or bacteria in the urine or blood. However, the use of prophylactic antibiotics before or immediately after invasive cystometry or urodynamic studies is not without risks of adverse effects and emergence of resistant microbes.

OBJECTIVES

To assess the effectiveness and safety of administering prophylactic antibiotics in reducing the risk of urinary tract infections after urodynamic studies. The hypothesis was that administering prophylactic antibiotics reduces urinary tract infections after urodynamic studies.

SEARCH METHODS

We searched the Cochrane Incontinence Group Specialised Trial Register, MEDLINE (January 1966 to January 2009), CINAHL (January 1982 to January 2009), EMBASE (January 1966 to January 2009), PubMed (1 January 1980 to January 2009), LILACS (up to January 2009), TRIP database (up to January 2009), and the UK NHS Evidence Health Information Resources (searched 10 December 2009). We searched the reference lists of relevant articles, the primary trials and the proceedings of the International Urogynaecological Association International Continence Society and the American Urological Association for the years 1999 to 2009 to identify articles not captured by electronic searches. There were no language restrictions.

SELECTION CRITERIA

All randomized controlled trials and quasi-randomized trials comparing the use of prophylactic antibiotics versus a placebo or no treatment in patients having urodynamic studies were selected. Two authors (PL and RF) independently performed the selection of trials for inclusion and any disagreements were resolved by discussion.

DATA COLLECTION AND ANALYSIS

All assessments of the quality of trials and data extraction were performed independently by two authors of the review (PL and RF) using forms designed according to Cochrane guidelines. We attempted to contact authors of the included trials for any missing data. Data were extracted on characteristics of the study participants including details of previously administered treatments, interventions used, the methods used to measure infection and adverse events.Statistical analyses were performed according to Cochrane Collaboration guidelines. Data from intention-to-treat analyses were used where available. For the dichotomous data, results for each study were expressed as a risk ratio (RR) with 95% confidence interval (CI) and combined for meta-analysis using the Mantel-Haenszel method.The primary outcome was urinary tract infection. Heterogeneity was assessed by the P value and I(2) statistic.

MAIN RESULTS

Nine randomized controlled trials involving the prophylactic use of antibiotics in patients having urodynamic studies were identified and these included 973 patients in total; one study was an abstract. Two further trials were excluded from the review. The methods of the included trials were poorly described.The primary outcome in all trials was the rate of developing significant bacteriuria, defined as the presence of more than 100,000 bacteria per millilitre of a mid-stream urine sample on culture and sensitivity testing. The other outcomes included pyrexia, haematuria, dysuria and adverse reactions to antibiotics.The administration of prophylactic antibiotics when compared to a placebo reduced the risk of significant bacteriuria (4% with antibiotics versus 12% without, risk ratio (RR) 0.35, 95% CI 0.22 to 0.56) in both men and women. The administration of prophylactic antibiotics also reduced the risk of haematuria (RR 0.46, 95% CI 0.23 to 0.91). However, there was no statistically significant difference in the primary outcome, risk of symptomatic urinary tract infection (40/201, 20% versus 59/214, 28%; RR 0.73, 95% CI 0.52 to 1.03); or in the risk of fever (RR 5.16, 95% CI 0.94 to 28.16) or dysuria (RR 0.83, 95% CI 0.5 to 1.36). Only two of 135 people had an adverse reaction to the antibiotics. The number of patients needed to treat with antibiotics to prevent bacteriuria was 12.3. Amongst women, the number needed to treat to prevent bacteriuria was 13.4; while amongst men it was 9.1 (number needed to treat = 1/ absolute risk reduction).

AUTHORS' CONCLUSIONS

Prophylactic antibiotics did reduce the risk of bacteriuria after urodynamic studies but there was not enough evidence to suggest that this effect reduced symptomatic urinary tract infections. There was no statistically significant difference in the risk of fever, dysuria or adverse reactions. Potential benefits have to be weighed against clinical and financial implications, and the risk of adverse effects.

Systematic review of urological followup after spinal cord injury

PURPOSE

There is no consensus on the appropriate urological followup of individuals after spinal cord injury but it is well known that they are at risk for renal deterioration, bladder cancer and stones. We systematically reviewed the literature to evaluate evidence of urological screening in this population.

MATERIALS AND METHODS

We reviewed 385 abstracts, of which 50 met study inclusion criteria. We rated evidence using American Academy of Neurology 2004 guidelines.

RESULTS

A total of 12 articles evaluated urinary tract infection screening. Patient reported symptoms used to predict urinary tract infection yielded mixed results and urine dipstick testing had the same accuracy as microscopy. Routine urine culture was unnecessary in healthy, asymptomatic individuals with normal urinalysis. Urodynamics probably must be done periodically (6 articles) but there was no information on frequency. In 11 articles ultrasound was recommended as a useful, noninvasive and possibly cost-effective screening method. Renal scan was a good method for further testing, especially if ultrasound was positive (11 articles). Evidence was sufficient (11 articles) to recommend ultrasound of the urinary tract to detect urinary tract stones with good sensitivity but not plain x-ray of the kidneys, ureters and bladder (2 articles). There was insufficient evidence to recommend urine markers or cytology for bladder cancer screening (9 articles).

CONCLUSIONS

Based on this review no definitive recommendations for screening can be made except routine renal ultrasound. Urodynamics are an important part of screening but the frequency is unclear. The optimum bladder cancer screening method has not been defined.

Managing the urinary tract in spinal cord injury

This review sets out to provide an overview of the author's approach to the management of the urinary tract in the patient who has suffered from an injury to their spinal cord. Emphasis is given to the need to understand the fundamental pathophysiological patterns that are seen with injuries that involve the sacral segments of the cord (the conus) and those that spare the conus but interrupt communication between the sacral parasympathetic and somatic centers and the brain (supraconal lesions). The importance of patient participation in management decisions is highlighted by considering the different ways in which the urinary tract can be managed and how the clinician needs to try to meet patient expectations and requirements while establishing safe urological management. Finally, consideration is given to the importance of establishing an appropriate follow up regime and managing urinary tract complications effectively.

Urological care of the spinal cord-injured patient

Spinal cord injury (SCI) is a catastrophic occurrence affecting the lives of 11,000 people in the United States every year. Urologic complications account for much of the morbidity associated with SCI and as much as 15% of the associated mortality. Spinal cord-injured patients are required to digest a plethora of self-management information during the emotionally and psychologically distressing period immediately following their injury. As a vital resource in the SCI patients' recovery process, it is crucial for the WOC nurse to have knowledge of the specialized needs of this population. This article reviews the effects of SCI on bladder function, discusses potential complications of the neurogenic bladder, and provides an overview of management options to assist the patient in adaptation and restoration of quality of life.

Prophylactic antibiotics in urodynamics: A systematic review of effectiveness and safety

AIMS

To assess the effectiveness and safety of administering prophylactic antibiotics in reducing the risk of urinary tract infection (UTI) after urodynamic studies (UDS).

METHODS

The CENTRAL, MEDLINE, EMBASE, CINAHI, LILIACS (up to January 2007), TRIP database, The National Library for Health, the citation lists of review articles, conference abstracts (2004-2006) and hand search of reference lists to identify relevant reviews and articles. Randomised controlled trials (RCTs) comparing effectiveness of prophylactic antibiotics with placebo or nothing in reducing bacteriologically proven UTI after invasive cystometry were included. Two reviewers extracted data independently and the results were expressed as peto odds ratio with 95% confidence intervals using fixed effects model in ReV Man 4.2.8 software.

RESULTS

Eight RCTs with 995 patients were included. The majority of the patients were female. The studies were methodologically poor. The primary outcome in all but one study was newly acquired infection defined as colony count >10(5)/ml in urine tested post UDS. On meta-analysis, there was 40% reduction in the risk of significant bacteriuria with administration of prophylactic antibiotics (Peto odds ratio 0.39; 95% confidence interval 0.24-0.61). The antibiotics used differed in dose, type and duration. One minor skin rash and one major anaphylactic reaction requiring steroid injection therapy was reported in the treatment group. One would need to give prophylactic antibiotics to 13 individuals undergoing UDS to prevent one significant bacteriuria of unknown clinical significance.

CONCLUSION

The use of prophylactic antibiotics in urodynamics reduces the risk of significant bacteriuria.

Antibiotic therapy for patients with spinal cord injury undergoing urologic procedures

This prospective study was performed to determine whether gentamicin can be prescribed routinely to patients with spinal cord injury undergoing urologic procedures, or whether antibiotic therapy must be selected on the basis of recent urine microbiologic test results. Between January 2004 and June 2005, procedures were performed on 38 patients, all of whom were prescribed antibiotics on the basis of a microbiology report. Sixteen patients who underwent urologic surgery during 2003 and received gentamicin empirically served as a control group. The patients' clinical course was monitored for postprocedure sepsis. Only 12 patients received gentamicin as the sole antibiotic; 10 patients required an additional antimicrobial for urine samples that grew more than 1 organism and contained bacteria resistant to gentamicin; 26 patients needed antibiotics other than gentamicin for gentamicin-resistant uropathogens. Three patients with organisms sensitive to gentamicin as well as another antibiotic received an agent considered less nephrotoxic than gentamicin. After the procedure, sepsis occurred in only 1 patient, a man with chronic lymphocytic leukemia and small cell carcinoma of the urinary bladder. Three control group patients developed a fever in excess of 39 degrees C. One of these patients did not require a change of antibiotic, another patient recovered after 3 changes of antibiotic, and the third patient recovered from septicemia after receiving ventilatory support. Antibiotics should be prescribed on the basis of recent urine microbiologic test results, and empiric therapy with gentamicin should be avoided in patients with spinal cord injury who are scheduled to undergo urologic procedures.