how to manage and prevent urinary tract infections in neuropathic bladder in neuropathic bladder how...
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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