Limitations
This study has several limitations. First, the sample size was much smaller than expected. Of the 355 charts reviewed, only 86 met all the criteria to be included, which limited analysis. Additionally, given the retrospective nature of the study, it was impossible to determine provider rationale for the treatment. Since a diagnosis of UTI in patients with SCI often cannot be done with conventional methods due to lack of symptoms, many investigators have emphasized the use of quantitative urinalysis to differentiate true infection vs contamination.15-17
According to the National Institute on Disability and Rehabilitation Research consensus conference recommendations, the definition of significant bacteriuria will vary, depending on the method of bladder drainage.18 While this study reviewed microbiologic cultures and the type of patient’s urinary catheter, the method of bladder drainage in the context of quantitative urinalysis was not evaluated, which limited the interpretation of microbiologic data.
It was also impossible to determine whether bacteria were cleared by the initial treatment, leading to new bacterial strains with a multidrug resistance, or whether patients relapsed. While antibiotic selection was appropriate for antimicrobial coverage, this study was not designed to detect potential inadequacies in dosing, which could also affect resistance. Last, since no genetic evaluation of the microorganisms was done, the authors cannot be sure whether the microorganisms noted on the first urine culture were of the same genetic makeup as those identified in the second urine culture.
Conclusion
Optimal duration of therapy for treatment of UTIs in patients with SCI is unclear. Despite its limitations, the study suggests exposure to longer antibiotic treatment courses may lead to increased antimicrobial resistance in the urinary tract organisms in this patient population. Further investigation with a larger sample size is required to confirm these findings.
Author disclosures
Dr. Bedimo received research grant funding from Janssen Pharmaceuticals and Merck and Company. He also serves as an ad hoc scientific advisor for Viiv Healthcare, Gilead Science, and BMD Science. All other authors report no actual or potential conflicts of interest with regard to this article.
Disclaimer
The opinions expressed herein are those of the authors and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the U.S. Government, or any of its agencies. This article may discuss unlabeled or investigational use of certain drugs. Please review complete prescribing information for specific drugs or drug combinations—including indications, contraindications, warnings, and adverse effects—before administering pharmacologic therapy to patients.
References
1. Saint S, Lipsky BA. Preventing catheter-related bacteriuria: Should we? Can we? How? Arch Intern Med. 1999;159(8):800-808.
2. Laupland KB, Bagshaw SM, Gregson DB, Kirkpatrick AW, Ross T, Church DL. Intensive care unit-acquired urinary tract infections in a regional critical care system. Crit Care. 2005;9(2):R60-R65.
3. Girard R, Mazoyer MA, Plauchu MM, Rode G. High prevalence of nosocomial infections in rehabilitation units accounted for by urinary tract infections in patients with spinal cord injury. J Hosp Infect. 2006;62(4):473-479.
4. Cardenas DD, Hooton TM. Urinary tract infection in persons with spinal cord injury. Arch Phys Med Rehabil. 1995;76(3):272-280.
5. Salomon J, Gory A, Bernard L, Ruffion A, Denys P, Chartier-Kastler E. [Urinary tract infection and neurogenic bladder]. Prog Urol. 2007;17(3):448-453.
6. Ena J, Amador C, Martinez C, Ortiz de la Tabla V. Risk factors for acquisition of urinary tract infections caused by ciprofloxacin resistant Escherichia coli. J Urol. 1995;153(1):117-120.
7. Allen UD, MacDonald N, Fuite L, Chan F, Stephens D. Risk factors for resistance to “first-line” antimicrobials among urinary tract isolates of Escherichia coli in children. CMAJ. 1999;160(10):1436-1440.
8. De Mouy D, Cavallo JD, Armengaud M, et al. [Urinary tract infection in an urban population: Etiology and antibiotic sensitivity as a function of patient history]. Presse Med. 1999;28(30):1624-1628.
9. Waites KB, Chen Y, DeVivo MJ, Canupp KC, Moser SA. Antimicrobial resistance in gram-negative bacteria isolated from the urinary tract in community-residing persons with spinal cord injury. Arch Phys Med Rehabil. 2000;81(6):764-769.
10. Shah PS, Cannon JP, Sullivan CL, Nemchausky B, Pachucki CT. Controlling antimicrobial use and decreasing microbiological laboratory tests for urinary tract infections in spinal-cord-injury patients with chronic indwelling catheters. Am J Health Syst Pharm. 2005;62(1):74-77.
11. Weber DJ, Raasch R, Rutala WA. Nosocomial infections in the ICU: The growing importance of antibiotic-resistant pathogens. Chest. 1999;115(suppl 3):34S-41S.
12. Naber KG, Bergman B, Bishop MC, et al; Urinary Tract Infection (UTI) Working Group of the Health Care Office (HCO) of the European Association of Urology (EAU). EAU guidelines for the management of urinary and male genital tract infections. Urinary Tract Infection (UTI) Working Group of the Health Care Office (HCO) of the European Association of Urology (EAU). Eur Urol. 2001;40(5):576-588.