How to manage and prevent How to manage and prevent urinary tract infectionsurinary tract infections in neuropathic bladderin neuropathic bladder

How to manage and prevent How to manage and prevent urinary tract infectionsurinary tract infections in neuropathic bladderin neuropathic bladder

Department of Urology, St. Vincent’s Hospital Department of Urology, St. Vincent’s Hospital

The Catholic University of Korea, College of MedicineThe Catholic University of Korea, College of Medicine

하 유 신하 유 신

Chronic or recurrent urinary tract infectionwith neurogenic bladder dysfunction

Nosocomial infection, in itself

High morbidity, frequent hospitalization, costs

What is the optimal management?

Renal insufficiency

Structural/physiological factors overdistension of the bladder

high-pressure voiding

large PVR

stone

outlet obstruction ex. BPH, urethral stricture, DSD

Behavioral factors patient’s knowledge

personal hygiene

social support systems

age, gender

Predisposing factorsPredisposing factors

Structural/physiological factorsStructural/physiological factorsStructural/physiological factorsStructural/physiological factors

Detrusor overactivity

Detrusor sphincter dyssynegia

Structural/physiological factorsStructural/physiological factorsStructural/physiological factorsStructural/physiological factors

VUR

Frequent catheterization

Structural/physiological factorsStructural/physiological factorsStructural/physiological factorsStructural/physiological factors

Infection

High detrusor leak P.

VUR

DSD, BOO, Stricture

High residual VHigh pressure storage

VUR

Renal damage

Detrusor overactivity

Intravesical pressure

Have not been so well studied

Behavioral factorsBehavioral factorsBehavioral factorsBehavioral factors

patient’s knowledge of the urinary system

personal hygiene

adjustment to disability

social support systems

age

gender

May have association with UTI

Method of urinary drainage indwelling urethral cath. – 100% by day 4 c open system

20% by day 15 c closed system

85-95% thereafter

incidence of UTI

Stamm ; Am J Med 1991Perkash ; Urol North Am 1993

Indwelling cath. CIC Condom cath.

5 episode

/100 person day

0.41 episode

/100 person day

0.36 episode

/100 person day

Esclarin et al ; J Urol 1991King et al ; Arch Phys Med Rehabil 1992

Indwellng urethral cath.

– important risk factor

Study of catheter free outpatients

poor personal hygiene ethnicity less-than daily condom cath. changes

bladder drainage method (CIC vs condom cath.)

age gender neurological injury level

Correlation with UTI

Not correlation

Waites et al ; Arch Phys Med Rehabil 2000

Typical manifestations of symptomatic UTI frequency, dysuria ; early Sx. usually absent in patients c neurogenic bladder dysfunction May be delayed or missed Fever Discomfort Incontinence Increased spaciticity Autonomic hyperreflexia

Clinical symptoms and DiagnosisClinical symptoms and Diagnosis

Suggestive of UTI

Pyuria – present in the great majority who have indwelling

catheter or intermittent catherization

Diagnosis for UTIDiagnosis for UTIDiagnosis for UTIDiagnosis for UTI

Bacteriuria – different criteria for significant bacteriuria

Sign & symptoms are often subtle, so diagnosis may be

missed or delayed

Controversy, difficult and comprehensive consideration

Bacteriuria

Colonization

Urinary tract infection

Asymptomatic bacteriuria

Definitions

Diagnostic criteria for UTIDiagnostic criteria for UTIDiagnostic criteria for UTIDiagnostic criteria for UTI

Stover et al ; Arch Phys Med Rehabil 1989

Bacteria isolated from urine irrespective of collection method & Sx

Bacteriuria without tissue invasion

Microbial invasion of the urinary tract

Bacteriuria without clinical Sx.

Bladder drainage method

Sampling method Criteria (CFU/ml)

intermittent catheterization

catheter specimen 102

catheter free males using condom

clean-void 104

indwelling catheters Through catheter or Suprapubic aspiration

any detectable concentration

Significant bacteriuria

National institure on Disability and Rehabilitation Research ; 1992

Colonization vs Urinary tract infection National institure on Disability and Rehabilitation Research ; 1992

Pyuria

- irritative effect of the cath. on the bladder wall

- low specificity in individuals c indwelling cath.

Bacteriuria Pyuria Symptoms

Colonization + - -

Urinary tract infection + + + or -

Today, we don’t have the exact method to determine

if tissue invasion has occurred or not

When to treat colonization, asymptomatic bacteriuria, symptomatic bacteriuria

Which antibiotics to choice Empirical therapy Susceptibility based choice Area-specific surveillance

Management of predisposing factor

ManagementManagement

Pyuria –

When to treatWhen to treatWhen to treatWhen to treat

Laboratory results may be misleading and overtreat patients

or fail to recognize and treat early infection

Cardenas & Hooton ; Arch Phys Med Rehabil 1995

Bacteriuria –

?

?

present in the great majority who have indwelling

catheter or intermittent catherization

in almost all individuals with indwelling cath.

• 64 cath.-free spinal cord injury pt

• asymptomatic pt

•

Waites et al ; paraplegia 1993

To evaluate the microbial efficacy of antimicrobial Tx

Group1 Group2

Duration of antibiotics 7-14 >28

Relapse or reinfection 93% 85%

Median days to

relapse or reinfection16 27

Drug resistance <<

• 14 neurogenic bladder c CIC

• asymptomatic bacteriuria pt

• total 323 observed patient wks

• only 5 symptomatic infections

Schlager et al ; J Ped 1995

Asymptomatic bacteriuria will lead to symptomatic infection and renal damage ?

Bacteriuria persist for weeks in symptom and renal damage free state

General agreement that asymptomatic bacteriuria should not be treated

When to treatWhen to treatWhen to treatWhen to treat

Fever & chillis Autonomic dysrefexia

; sweating , spasticity, restlessness, increased blood pressure change in voiding pattern

Only should be treated for bacteriuria if they have symptoms

culture with susceptibility test normal flora single agent ‘reserve’ antibiotics surveillance

Which antibiotics to choiceWhich antibiotics to choiceWhich antibiotics to choiceWhich antibiotics to choice

Sauerwein ;IJAA 2002Biering-Sorenen et al ; Drugs 2001

Antibiotic policy in patients c neurogenic bladderEmpirical treatment

Biering-Sorenen et al ; Drugs 2001

Fluoroquinolone, aminopenicillin c BLI, 2nd or 3rd cephalosporin

in complicated UTIs d/t urological disorders

EAU guideline ; 2006

Which antibiotics to choiceWhich antibiotics to choiceWhich antibiotics to choiceWhich antibiotics to choice

Empirical treatment the drugs used should be those where the prevalence of resistance among

the most common UTI pathogens is less than 10 to 20%

require a knowledge of the spectrum of possible pathogen and local

antibiotic resistance pattern

Warren et al ; Clin Infect Dis 1999

EAU guideline ; 2006

In Korea ?

Survey was carried out with participation of 22 hospitals in South Korea, 2006

Int J Antimicrob Agents In Press

  Organism

No. isolates

% of total

Enterobacteriaceae(81.7%)

E. coliKlebsiella spp.Enterobacter spp.Citrobacter spp.Proteus spp.

214 11 9 9 3

71.1% 3.7% 3.0% 3.0% 1.0%

Non-Enterobacteriaceae(18.3%)

EnterococciCNS

39 16

13.0% 5.3%

Isolates from acute uncomplicated cystitis in 301 patient

Susceptibility of urinary Enterobacteriaceae isolates from female outpatients with acute uncomplicated cystitis to various antimicrobial agents

Antimicrobial agent

Percentage of susceptible strains in 2006/2002

E. coli Other Enterobacteria

ceae Total

Ampicillin 35.2/37.2 6.3/15.0 31.4/35.5

Ampicillin/Sulbactam 52.4/44.5 51.6/50.0 52.3/45.0

Piperacillin/Tazobactam 98.6/97.4 90.6/95.0 97.6/97.2

Ciprofloxacin 76.6/84.8 93.8/95.0 78.9/85.7

Gatifloxacin 78.2/N.A. 93.8/N.A. 80.3/N.A.

Cefazolin 92.4/92.2 50.0/60.0 86.8/89.1

Amikacin 99.5/99.0 100/100 99.6/99.1

Gentamicin 77.6/81.7 100/80 80.5/81.5

Tobramycin 78.2/85.9 100/80 81.1/85.3

TMP/SMX 70.6/61.3 96.8/70 73.9/62.1

In Korea 2006 , Survey of acute bacterial prostatitis

` E.coli (%) Other pathogens (%)Ampcillin/sulbactam 42.3 30.0

Piperacillin/tazobactam 95.0 71.4

TMP/SMX 71.4 50.0

1st cephalosporin 70.4 41.2

2nd cephalosporin 91.9 53.9

3rd cephalosporin 95.2 46.7

Amikacin 98.3 78.6

Gentamicin 90.5 65.0

Tobramycin 91.4 66.7

Ciprofloxacin 76.2 68.4

Int J Antimicrob Agents In PressAntibiotic susceptibility of pathogens isolated in patients with acute

bacterial prostatitis

Infection

High detrusor leak P.

VUR

DSD, BOO, Stricture

High residual VHigh pressure storage

High detrusor leak P.

VUR

Renal damage

Detrusor overactivity

Essential step in order to optimal management

Management of predisposing factorManagement of predisposing factorManagement of predisposing factorManagement of predisposing factor

High pressure bladderInsufficient emptying

Stable bladder

Low storage pressure

Low Detrusor leak pressure

Effective bladder emptying

General

Antiseptic and antibacterials agents Topical administration Antiseptic solution Urine pH Prophylactic antibiotics

Novel indwelling catheter Biofilm Silver-coated catheter Hydrogel-coated catheter Antibiotic-coated catheter

PreventionPrevention

GeneralGeneralGeneralGeneral

Recommendation Closed drainage system remove as soon as possible indwelling catheterization only when necessary, (ex. CIC) Hand hygiene Staff and pt education Smallest suitable cath.

Refrainment Irrigation ‘Bladder training’ change at fixed intervals Meatal care

Antiseptic and antibacterials agentsAntiseptic and antibacterials agentsAntiseptic and antibacterials agentsAntiseptic and antibacterials agents

Topical administration of antiseptic agents

Urine acidification (methenamine) formaldehyde and ammonia reduction in the frequency of pyelonephritis no clinical benefit influenced by diet

Antiseptic solution, bladder washout

Kevorkian ; Mayo Clinic Proc 1984 Krebs ; J Urol 1985 Castello et al ; Spinal cord 1996

No clinical benefit

Cranberry juice hippuric acid ; reduction of adherence large dropouts

Prophylactic antibiotics for individuals with indwelling cath. not to use for the prevention of UTI high risk of causing bacterial resistance benefit in selected situations

; netropenia & risk for endocarditis

Prevention

ascending colonization within biofilm mechanical barrier Protecting bacteria Resistant to antibiotics The central factor

Seek to alter the catheter surface in order to inhibit biofilm formation !!

Novel indwelling cathetersNovel indwelling cathetersNovel indwelling cathetersNovel indwelling catheters

Biofilm

Novel indwelling cathetersNovel indwelling cathetersNovel indwelling cathetersNovel indwelling catheters

Silver

Hydrogel

Antibiotics gentamicin Minocyclin-rifampin Cifloxacin norfloxacin nitrofurazone

Failed to demonstrate the efficacy of silver in prevention of CAUTI

insufficient evidence to recommend the use of hydrogel-catheters

Nitrofurazone-coated catheters

Silicone cath. Nitrofurazone coated

Scanning EM of the catheter surface from patients catheterized for 7 days

SJ Lee et al ; Int J Antimicrob Agents 2004

Effective during short term

No advantage during long term

Symptoms and Diagnosis

Optimal management

Administration antibiotics to only symptomatic UTI

Empirical Tx ; based on area-specific surveillance

Evaluation & management of predisposing factor

CONCLUSIONCONCLUSION

Subtle, may be delayed or missed

Different mirobiological criteria

Prevention

Keep general basic principle