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Full Title: Prevention and Management of Urinary Tract Infections in Paralyzed Persons
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Objectives: The objective was to analyze the evidence on aspects of the prevention and management of urinary tract infections in paralyzed persons. The two most common conditions affected are spinal cord injury (SCI) and multiple sclerosis (MS). Both conditions have a predilection for onset in young adulthood. 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 the 5th most common cause of death. Over 70 percent of persons with MS develop bladder dysfunction over the course of their disease.
Specific questions addressed were:
- What combination of signs, symptoms, and laboratory findings are associated with risks to this population?
- What are risk factors for recurrent UTIs?
- What are the risks and benefits of antibiotic prophylaxis?
Search Strategy: An expert and consumer panel was convened to focus the literature review. A research librarian performed a search of MEDLINE® (1966-January 1998) and EMBASE (1974-January 1998) databases, using the terms urinary tract, urinary tract infections, bacteriuria, paraplegia, quadriplegia, spinal cord injuries, multiple sclerosis, neurogenic bladder, and neuropathic bladder. CINAHL (1982-July 1998) was also searched. Some articles were identified by panel members and by review of reference lists.
Selection Criteria: All titles were reviewed, then abstracts of non-rejected titles, where available. Full-length articles were reviewed for accepted abstracts and for titles with no abstract. Selection criteria included human studies of adults and adolescents with neurogenic bladder due to spinal cord dysfunction and relevant to a key question, and non-acute SCI patients. Excluded were case reports, reviews, editorials, and letters, and studies published before 1979 on risk factors for recurrent UTI. For prophylaxis of UTI, only randomized controlled trials were included, as were studies of acute SCI.
Data Collection and Analysis: As articles were reviewed they were designated as addressing one of the key questions. Project investigators reviewed full-length articles and excluded those having insufficient data or not otherwise addressing a question. Data from remaining articles were extracted into evidence tables. Quality of controlled trials and of cohort studies was formally assessed. A formal meta-analysis was undertaken on prophylaxis of UTI. A draft evidence report was critiqued by 22 experts and consumers.
Main Results: 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 common in asymptomatic patients. The occurrence of febrile episodes in prior years is associated with upper urinary tract complications or abnormalities; bladder calculi are associated with prior cultures of certain bacterial species and of multiple organisms.
Other evidence regarding the significance of signs, symptoms, and laboratory findings is sparse or inconclusive due to study design limitations. Indwelling catheterization is associated with more frequent infections than bladder management methods not involving a catheter. The literature does not support firm conclusions regarding most other risk factors. Antibiotic prophylaxis reduces bacteriuria but is not associated with a reduced number of symptomatic infections in the populations studied and results in two-fold increases in the occurrence of antibiotic-resistant bacteria.
Conclusions: Febrile episodes are associated with the later occurrence of upper tract complications. Intermittent catheterization is associated with a lower risk of urinary tract infections. The regular use of antibiotic prophylaxis for most patients with spinal cord dysfunction cannot be supported.
Future research should focus in the areas of:
- 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).
- Large, multicenter prospective studies of risk factors—potentially modifiable risk factors, in particular—for urinary tract infection.
- Randomized controlled trials in the subgroup of patients who have frequent, recurrent urinary tract infections that limit their functioning.
Studies should include both SCI and MS patients, where feasible, and state-of-the-art methods for maximizing the quality of the study designs should be employed.
Prevention and Management of Urinary Tract Infections in Paralyzed Persons
Evidence-based Practice Center: Southern California
Topic Nominators: Paralyzed Veterans of America (including 30 local chapters), American Association of Spinal Cord Injury Psychologists,
American Congress of Rehabilitation Medicine, American Paraplegia Society, Association of Rehabilitation Nurses,
Consortium of Spinal Cord Medicine
Current as of January 1999