Prevention and Management of Urinary Tract Infections in Paralyzed Persons

27 Jul 2007

AHCPR - Evidence Report/Technology Assessment
January 1, 1999
Abstract Of Report:

Overview

The objective of this study was to analyze the evidence on selected aspects of the prevention and management of urinary tract infections in paralyzed persons. The two populations most commonly affected are persons having spinal cord injury (SCI) and people with multiple sclerosis (MS). Eighty percent of persons with SCI experience a urinary tract infection (UTI) by their 16th year post-injury, and diseases of the urinary system are overall the fifth most common primary or secondary cause of death in this population. Between 70 to 90 percent of persons with MS develop bladder dysfunction over the course of their disease, placing them at increased risk for UTIs. Urinary complications are responsible for a large proportion of hospitalization-related episodes in these patient populations. UTI is the most frequent secondary medical complication reported by the federally designated Model Spinal Cord Injury Systems during acute care and rehabilitation, and UTI was the primary or secondary diagnosis for nearly one-third of hospitalizations of MS patients over the age of 65, according to 1989 Medicare data.

Reporting the Evidence

The specific questions addressed in this report are:

What combination of signs, symptoms, and laboratory findings are associated with risks to persons with paralysis due to neurogenic bladder?

What are risk factors for recurrent UTIs?

What are the risks and benefits of long-term use of antibiotic prophylaxis?

The literature review for the first key question was broad and included studies of both short and long-term risks as related to episodes of various combinations of signs, symptoms, and laboratory findings. For the literature search on risk factors for UTI, types of risk factors examined were socioeconomic status, insurance status, behavioral factors, personal hygiene, sex, and domicile, as well as intermediate risk factors of bladder management method (or drainage), time since injury, and level of functioning (or injury). Regarding prophylaxis, the efficacy of any oral antibiotic therapy and the efficacy of specific oral antibiotics were examined.

Study samples in most of the published literature were patients with SCI.

Bacteriuria is a common occurrence; pyuria with bacteriuria may be associated with symptomatic infections, but these findings are also relatively common in asymptomatic patients.

There are convergent data from several large cohort and case-control studies that the occurrence of febrile episodes in prior years is associated with a higher occurrence of upper urinary tract complications or abnormalities at long-term follow-up.

The presence of certain c or of multiple organisms early after spinal cord injury is associated with an approximately three-fold increased odds for developing bladder calculi at 2 years, but the presence of other signs and symptoms and treatment status were not included in the single study of this issue that was identified.

Other evidence regarding the significance of signs, symptoms, and laboratory findings either is sparse or is inconclusive due to study design limitations.

Indwelling catheterization is associated with more frequent infections than that involving intermittent catheterization, which in turn is associated with more frequent infections than methods not involving a catheter (However, severity of disease affects choice of method, particularly the alternatives involving use of a catheter versus no catheter.).

The literature does not support firm conclusions regarding most other risk factors.

Antibiotic prophylaxis significantly reduces bacteriuria among acute spinal cord injury patients (p <0.05), and there is a trend for reduction in bacteriuria among non-acute spinal cord patients (p = 0.06). However, antibiotic prophylaxis is not associated with a reduced number of symptomatic infections in the populations studied.

Antibiotic prophylaxis results in a two-fold increase in the occurrence of antibiotic-resistant bacteria.

Future research should focus in the areas of (1) prospective cohort studies to assess the short-term and long-term significance of signs, symptoms, and laboratory findings (level of bacteriuria and type of organism, pyuria, others); (2) large, multi-center, prospective cohort or randomized trial studies of risk factors for UTIs, particularly targeting potentially modifiable risk factors like behavioral factors and catheterization techniques; and (3) randomized controlled trials in the subgroup of patients who have frequent, recurrent urinary tract infections that limit their daily functioning and well-being. These studies should include both SCI and MS patients, where feasible, and should enroll a sufficient number of patients for adequate statistical power to detect meaningful clinical differences. In addition to traditional clinical measures, these studies should also measure quality-of-life outcomes and costs. State-of-the-art methods for maximizing the quality of the study designs and the rigor with which they are executed should be employed.

The full Evidence Report was prepared for the Agency for Health Care Policy and Research by Southern California Evidence-based Practice Center/Rand Corporation, Santa Monica, CA, under contract No. 290-97-0001. It is expected to be available by mid-1999. At that time, printed copies may be obtained free of charge from the AHCPR Clearinghouse by calling 1-800-358-9295. Requesters should ask for Evidence Report/Technology Assessment No. 6, Prevention and Management of Urinary Tract infections In Paralyzed Persons (AHCPR Publication No. 99-E008). When available online, the Evidence Report will be at: http://www.ahcpr.gov/clinic/index.html#evidence.