Bacteriuria in the Elderly
UTIs in the elderly are a common and expanding health problem (Kaye, 1980). In 2003 there were almost 34 million Americans older than 65 years (U.S. Census Bureau, 2003). As the life expectancy increases, the diagnosis, treatment, morbidity, and mortality of UTIs in the elderly will assume increasing importance.
Epidemiology
At least 20% of women and 10% of men older than 65 years have bacteriuria (Boscia and Kaye, 1987). In contrast to young adults, in whom bacteriuria is 30 times more prevalent in women than in men, the ratio in women to men with bacteriuria progressively decreases to 2:1. Most elderly patients with bacteriuria are asymptomatic; estimates among women living in nursing homes range from 17% to 55%, as compared with 15% to 31% for their male cohorts (Nicolle, 1994). The prevalence of bacteriuria in the elderly increases with age (Table 10–27) (Sourander, 1966; Brocklehurst et al, 1968) and concurrent disease (Fig. 10–38) and may exceed 50% in selective groups (Boscia and Kaye, 1987; Schaeffer, 1991). Risk factors can be compounded. In a study of 373 women and 150 men older than 68 years, 24% of functionally impaired nursing home residents had bacteriuria compared with 12% of healthy domiciliary subjects (Boscia et al, 1986). Longitudinal studies have clarified the dynamic aspect of bacteriuria in the elderly with frequent, spontaneous alteration between positive and negative urine cultures (Monane et al, 1995) (Fig. 10–39). There is only a small pool of elderly patients with persistent bacteriuria (Kaye, 1980). The incidence of asymptomatic bacteriuria is much more common than is apparent from a single survey, implying that most elderly will eventually have episodes of bacteriuria (Boscia et al, 1986).
Table 10–27 Bacteriuria in Two Population Surveys
| AGE (yr) | MEN (%) | WOMEN (%) |
|---|---|---|
| 65-70 | 2-3 | 20-21 |
| >80 | 21-22 | 23-50 |
Data from Brocklehurst JC, Dillane JB, Griffiths L, et al. Prevalence and symptomatology of urinary infection in an aged population. Gerontol Clin 1968;10:242–53; and Sourander LB. Urinary tract infections in the aged: an epidemiological study. Ann Med Intern Fenn 1966;55(Suppl. 45):7–55.
Figure 10–38 Frequency of significant bacteriuria related to underlying disease.
(Adapted from Jackson GG, Arana-Sialer JA, Andersen BR. Profiles of pyelonephritis. Arch Intern Med 1962;110:663–75.)
Figure 10–39 Cumulative percentage of subjects (age = 65 years) with at least one positive urine culture survey result over three surveys performed at 6-month intervals.
(From Boscia JA, Kobasa WD, Knight RA, et al. Epidemiology of bacteriuria in an elderly ambulatory population. Am J Med 1986;80:208.)
Pathogenesis
The pathophysiology of increased susceptibility is multifactorial and poorly understood. Age-related changes include decline in cell-mediated immunity, neurogenic bladder dysfunction, increased perineal soiling as a result of fecal and urinary incontinence, increased incidence of urethral catheter placement, and, in women, changes in the vaginal environment associated with estrogen depletion (Schaeffer, 1991; Raz and Stamm, 1993). Increased receptivity of uroepithelial cells (Reid et al, 1984) and a decrease in prostatic and vaginal antimicrobial factors associated with changes in pH and levels of zinc and hormones have been observed (Boscia et al, 1986). Bacteriologic characteristics of infection in the elderly differ from those in younger patients (Baldassarre and Kaye, 1991). E. coli remains the most common uropathogen, causing 75% of these infections. There is a significant increase in the incidence of Proteus, Klebsiella, Enterobacter, Serratia, and Pseudomonas species, as well as enterococci. Bacteriuria due to gram-positive bacteria is much more common in elderly men than in elderly women (Jackson et al, 1962). S. saprophyticus is not seen in this population. Polymicrobial bacteriuria is more common among the elderly (Nicolle et al, 1987). The shift in the pattern of uropathogens, the high frequency of polymicrobial infections, and antimicrobial resistance in UTIs in the elderly are due in large part to the high frequency of institutionalization and hospitalization, catheterization, and antimicrobial usage in this population (Fig. 10–40).
Figure 10–40 Microbiology of urinary tract infections.
(Data compiled from Stark RP, Maki DG. Bacteriuria in the catheterized patient: what quantitative level of bacteriuria is relevant? N Engl J Med 1984;311:560–4; Kunin CM. Detection, prevention, and management of urinary tract infections. 4th ed. Philadelphia: Lea & Febiger; 1987. p. xiii; Nicolle LE, Bjornson J, Harding GKM. Bacteriuria in elderly institutionalized men. N Engl J Med 1983;309:1420–5; Krieger JN, Kaiser DL, Wenzel RP. Urinary tract etiology of bloodstream infections in hospitalized patients. J Infect Dis 1983;148:57–62.)
Laboratory Diagnosis
Diagnosis of bacteriuria and UTIs in the elderly can be difficult. Urinary tract symptoms are often absent, and concomitant disease can mask or mimic UTI. Even severe upper tract infections may not be associated with fever or leukocytosis (Baldassarre and Kaye, 1991). Therefore a high index of suspicion is warranted, and diagnosis should rely on the results of a carefully obtained urinalysis and culture. The presence of greater than 105 cfu/mL of urine remains the standard for diagnosis in these patients. However, counts of 102 or more bacteria are clinically significant in catheterized specimens (Kunin, 1987; Nicolle et al, 2005).
Pyuria alone is not a good predictor nor an indication for antimicrobial treatment of bacteriuria in this population (Ouslander et al, 1996; Nicolle et al, 2005). Boscia and associates (1989) reported that more than 60% of women with pyuria of 10 WBCs/mm3 or greater (noted in midstream specimens) did not have a concurrent bacteriuria. However, the absence of pyuria was a good predictor of the absence of bacteriuria.
Because urinary tract abnormalities can often predispose and complicate bacteriuria in the elderly, a thorough urologic evaluation is warranted. Renal dysfunction, calculi, hydronephrosis, urinary retention, neurogenic bladder dysfunction, and other abnormalities should be identified by serum creatinine measurement, excretory urography, CT, ultrasonography, urodynamics, and/or cystoscopy. The timing and sequence of these tests should be dictated by the clinical setting.
Significance of Screening Bacteriuria
Screening for asymptomatic bacteriuria in elderly residents in the community or long-term care facilities is not recommended (Nicolle et al, 1983; Nordenstam et al, 1986; Boscia et al, 1987; Abutryn et al, 1994). There is no documented relationship between asymptomatic bacteriuria and uncomplicated UTIs and worsening renal function in this population. The treatment of asymptomatic bacteriuria to improve incontinence has not been justified (Baldassarre and Kaye, 1991; Ouslander et al, 1995). Although studies have demonstrated decreased survival in bacteriuric patients compared with nonbacteriuric control subjects, it is unclear whether increased mortality rates and bacteriuria are causally related (Baldassarre and Kaye, 1991; Abutryn et al, 1994).
Studies that have found a significantly increased mortality among persons with bacteriuria have looked at populations that were heterogeneous in terms of age and underlying disease (Dontas et al, 1981; Latham et al, 1985). An age difference of only 2 years increases mortality by 20% (Dontas et al, 1968). Therefore, in the studies mentioned previously (Dontas et al, 1968) and others (Abutryn et al, 1994), it is not clear how much of the observed association between bacteriuria and mortality was due to differences in age between the bacteriuric and the abacteriuric groups. In a study of bacteriuria and mortality in a homogeneous 70-year-old population, the association between bacteriuria and mortality was weaker and linked to fatal diseases not attributable to bacteriuria (Dontas et al, 1968). Nicolle and associates (1987) randomized institutionalized women with bacteriuria to treatment or observation and followed these patients for more than 1 year. Treatment did not result in improved survival and was associated with a number of adverse effects.
Bacteriuria that leads to UTIs in elderly subjects in the presence of underlying structural urinary tract abnormalities (e.g., obstruction with hydronephrosis) or systemic conditions (e.g., severe diabetes mellitus) are clinically significant, can lead to renal failure, and require prompt therapy. In addition, UTIs caused by urea-splitting bacteria, such as Proteus or Klebsiella species that cause formation of infection stones, may also lead to severe renal damage.
Sepsis and its sequelae (sepsis syndrome and septic shock) are increasingly common in the elderly. This is in part due to the aggressive use of catheters (Kunin et al, 1992) and other invasive equipment, implantation of prosthetic devices, and the administration of chemotherapy to cancer patients or corticosteroids in other immunosuppressed patients with organ transplants or inflammatory diseases. In addition, modern medical care has given longer life spans to the elderly and patients with metabolic, neoplastic, or immunodeficiency disorders, who remain at increased risk for infection.
Management
Prospective randomized comparative trials of antimicrobial or no therapy in elderly male and female nursing home residents with asymptomatic bacteriuria consistently document no benefit of antimicrobial therapy. There was no decrease in symptomatic episodes and no improvement in survival. In fact, treatment with antimicrobial therapy increases the occurrence of adverse drug effects and reinfection with resistant organisms and increases the cost of treatment. Therefore asymptomatic bacteriuria in elderly residents of long-term care facilities should not be treated with antimicrobial agents.
If patients present with lower tract symptoms, 7 days of therapy is recommended. For individuals presenting with fever or more severe systemic infection 10 to 14 days of therapy is recommended. The goal in this population is to eliminate symptoms but not sterilize the urine (McMurdo and Gillespie, 2000).
The 10% to 15% decrease in susceptibility of uropathogens to β-lactams, TMP-SMX, and fluoroquinolones in isolates from nursing home residents is disturbing and most likely due to a pattern of empirical prescribing in the nursing homes. In contrast, the susceptibility of isolates from patients with acute uncomplicated UTI in an outpatient setting has not changed appreciably in 10 years. The difference in susceptibility between the isolates from the outpatient and nursing home settings can be attributed to the presence of additional risk factors for antimicrobial resistance in the latter group. These risk factors include frequent antimicrobial usage, overcrowding, underlying pathology, and the presence of catheters and other invasive devices. Antimicrobial use needs to be guided by current surveillance studies of targeted uropathogenic bacteria and implemented (Vromen et al, 1999).
The elderly population is more susceptible than young patients to the toxic and adverse effects of antimicrobial agents (Grieco, 1980; Carty et al, 1981; Boscia et al, 1986) because the metabolism and excretion of antimicrobial agents may be impaired and the resulting increased serum levels can further damage renal function. Interactions with other medications can occur (Stahlmann and Lode, 2003). The safety margin between therapeutic and toxic doses is significantly narrowed. Therefore antimicrobial agents must be used judiciously, and dosing and drug levels should be carefully monitored.
The fluoroquinolones are effective in this population, and the side effects are not more apparent than in a younger population. However, fluoroquinolones can cause QT interval prolongation; therefore they should be avoided in patients with known prolongation of the QT interval, patients with uncorrected hypokalemia or hypomagnesemia, and patients receiving some antiarrhythmic agents (Stahlmann and Lode, 2003).
Chondrotoxicity of fluoroquinolones has led to restricted use in pediatric patients, but there is no indication that similar effects could occur in joint cartilage of adults. Tendinitis and tendon ruptures have occurred in rare cases. Chronic renal diseases, concomitant use of corticosteroids, and age older than 60 years have been recognized as risk factors for fluoroquinolone-induced tendon disorders (Stahlmann and Lode, 2003).
Key Points
Bacteriuria in the Elderly
Catheter-Associated Bacteriuria
Catheter-associated bacteriuria is the most common hospital-acquired infection, accounting for up to 40% of such infections and more than 1 million per year (Haley et al, 1985; Stamm, 1991). The development of bacteriuria in the presence of an indwelling catheter is inevitable and occurs at an incidence of approximately 10% per day of catheterization. Sterile and clean intermittent catheterization has been associated with rates of bacteriuria ranging from 1% to 3% per catheterization (Warren, 1997). The most important risk factors associated with increased likelihood of developing catheter-associated bacteriuria are duration of catheterization, female gender, absence of systemic antimicrobial agents, and catheter-care violations (Stamm, 1991). Most catheter-associated UTIs are asymptomatic. In patients with short-term catheter placement, only 10% to 30% of bacteriuric episodes produce typical symptoms of acute infection (Haley et al, 1981; Hartstein et al, 1981). Similarly, although patients with long-term catheters are bacteriuric, the incidence of febrile episodes occurs at a rate of only 1 per 100 days of catheterization (Warren, 1991). The extra direct cost associated with catheter-associated UTIs is about $600 per year per patient. The nosocomial costs for E. coli infections with relatively susceptible strains are considerably lower than for those caused by resistant gram-negative bacteria, which often require expensive parenteral antimicrobial therapy (Tambyah et al, 2002). Recently, the Center for Medicare Services (CMS) announced that they will no longer reimburse hospitals for the extra costs resulting from catheter-associated UTIs.
Pathogenesis
Bacteria enter the urinary tract of a catheterized patient by several routes. Bacteria can be introduced at the time of initial catheter placement by either mechanical inoculation of urethral bacteria or contamination from poor technique. Subsequently the bacteria most commonly gain access via a periurethral or intraluminal route (Stamm, 1991). In women, periurethral entry is the most prevalent. Daifuku and Stamm (1984) found that among 18 women who developed catheter-associated bacteriuria, 12 had antecedent urethral colonization with the infecting strain. Bacteria may also enter the drainage bag and follow the intraluminal route to the bladder. This route is particularly common in patients who are clustered among other patients with indwelling catheters (Maizels and Schaeffer, 1980; Tambyah et al, 1999).
The urinary catheter system provides a unique environment that allows for two distinct populations of bacteria: those that grow within the urine and another population that grows on the catheter surface. A biofilm represents a microbial environment of bacteria embedded in an extracellular matrix of bacterial products and host proteins that often lead to catheter encrustation (Stamm, 1991; Bonadio et al, 2001). Certain bacteria, particularly of the Pseudomonas and Proteus species, are adept at biofilm growth, which may explain their higher incidence in this clinical setting (Mobley and Warren, 1987). The uropathogens isolated from the catheterized urinary tract often differ from those found in noncatheterized ambulatory patients. E. coli is still the most common organism isolated, but Pseudomonas, Proteus, and Enterococcus species are very prevalent (Warren, 1991). In patients with long-term catheterization of more than 30 days, the bacteriuria is usually polymicrobial and the presence of four or five pathogens is not uncommon (Warren et al, 1982). Although certain species may persist for long periods, the bacterial populations in these patients tend to be dynamic.
Clinical Presentation
Most patients are asymptomatic. Suprapubic discomfort and development of fever, chills, or flank pain may indicate a symptomatic UTI.
Laboratory Diagnosis
Significant bacteriuria in patients with catheters is present when greater than 100 cfu/mL is present because even this low level progresses to greater than 105 cfu/mL in almost all patients (Maizels and Schaeffer, 1980; Stark and Maki, 1984). Pyuria is not a discriminate indicator of infection in this population.
Management
Careful aseptic insertion of the catheter and maintenance of a closed dependent drainage system are essential to minimize development of bacteriuria. The catheter-meatal junction should be cleaned daily with water, but antimicrobial agents should be avoided because they lead to colonization with resistant pathogens, such as Pseudomonas.
Incorporation of silver oxide (Schaeffer et al, 1988) or silver alloy (Saint et al, 1998) into the catheter and hydrogen peroxide into the drainage bag has been reported to decrease the incidence of bacteriuria in some studies (Schaeffer et al, 1988) but not in other populations (Stamm, 1991). The major benefit of silver alloy is in decreasing the likelihood of bacteriuria in hospitalized adults catheterized for the short-term (Saint et al, 2000; Newton et al, 2002; Brosnahan et al, 2004). If an asymptomatic catheterized patient has had an indwelling catheter for 3 or more days, and will have the catheter removed, a dipstick test can be used to rule out bacteriuria (Tissot et al, 2001). Concurrent administration of systemic antimicrobial agents transiently decreases the incidence of bacteriuria associated with short-term catheterization, but after 3 to 4 days the incidence of bacteriuria is similar to the rate in catheterized patients not taking systemic antimicrobials agents, and the prevalence of resistant bacteria and side effects is substantial. The concept of instilling nonvirulent bacteria into the bladder to completely block colonization and infection by pathogens has been tested in patients with spinal cord injuries (Hull et al, 2000). Patients successfully colonized with the nonvirulent strain had reduced symptomatic UTI and a subjective improvement in quality of life.
Patients with indwelling catheters should be treated only if they become symptomatic (e.g., febrile). Urine cultures should be performed before initiating antimicrobial therapy. The antimicrobial agent should be discontinued within 48 hours of resolution of the infection. If the catheter has been indwelling for several weeks, encrustation may shelter bacteria from the antimicrobial agent; therefore the catheter should be changed.
When a catheter is to be removed and there is a high probability of bacteriuria or the dipstick test is positive, a culture should be obtained 24 hours before removal (Tissot et al, 2001). If the probability is low or the dipstick is negative, a culture may not be necessary. The patient should be started on empirical antimicrobial therapy such as TMP-SMX or a fluoroquinolone just before decatheterization and maintained on therapy for 2 days. A post-therapy culture should be obtained 7 to 10 days later to confirm the eradication of the bacteriuria.
Key Points
Catheter-Associated Bacteriuria
Management of UTI in Patients with Spinal Cord Injury
Patients with spinal cord injury have unique concerns that affect the risk, diagnosis, and management of UTIs, which are all considered complicated.
Epidemiology
UTIs are among the most common urologic complications of spinal cord injury. It has been estimated that approximately 33% of spinal cord-injured patients have bacteriuria at any time (Stover et al, 1989) and that eventually almost all of spinal cord-injured patients will become bacteriuric and many will suffer significant morbidity and mortality. One prospective study of patients on intermittent catheterization or condom catheterization reported an incidence of significant bacteriuria of 18 episodes per person per year and an annual incidence of febrile UTIs of 1.8 per person per year (Waites et al, 1993). In addition, UTI is the most common cause of fever in the spinal cord–injured patient (Beraldo et al, 1993). The 1992 National Institute on Disability and Rehabilitation Research Consensus Conference (1993) examined the problems associated with UTIs in spinal cord–injured patients. Among the risk factors identified were impaired voiding, overdistention of the bladder, elevated intravesical pressure, increased risk of urinary obstruction, vesicoureteral reflux, instrumentation, and increased incidence of stones. Other factors that have been implicated are decreased fluid intake, poor hygiene, perineal colonization, decubiti and other evidence of local tissue trauma, and reduced host defense associated with chronic illness (Gilmore et al, 1992; Waites et al, 1993).
Pathogenesis
The method of bladder management has profound impact on UTI. The National Institute on Disability and Rehabilitation Research Consensus Conference (1993) noted that indwelling catheters were most likely to lead to UTI and that the vast majority of patients with an indwelling catheter for 30 days are bacteriuric. Suprapubic catheters and indwelling urethral catheters eventually have an equivalent infection rate (Kunin et al, 1987; Tambyah and Maki, 2000; Biering-Sorensen, 2002). However, the onset of bacteriuria may be delayed using a suprapubic catheter compared with a urethral catheter. During a 2-year period, 170 patients with spinal cord injury were evaluated regarding type of urinary drainage and infection (Warren et al, 1982). In patients using indwelling urethral catheters, all urine cultures were positive. The corresponding values for the suprapubic catheter group were 44%. Condom drainage systems are also associated with an incidence of bacteriuria from 63% (Dukes, 1928) to almost 100% (Pyrah et al, 1955).
Since its introduction by Lapides and colleagues (1972), clean (but not sterile) intermittent catheterization (CIC) has earned general recognition in the management of spinal cord injury patients (National Institute on Disability and Rehabilitation Research, 1993). Although never rigorously compared with indwelling urethral catheterization, CIC has been shown to decrease lower tract complications by maintaining low intravesical pressure and reducing the incidence of stones (Stover et al, 1989). CIC also appears to reduce complications associated with an indwelling catheter, such as UTI, fever, bacteremia, and local infections such as epididymitis and prostatitis. Weld and Dmochowski (2000) followed 316 patients with spinal cord injury with different bladder management for a mean of 18.3 years and recorded all complications. The CIC group had statistically significantly lower complication rates compared with the urethral catheterization group and no significantly higher complication rates relative to all other management methods for each type of complication studied. Thus it is generally agreed that CIC places patients with spinal cord injury at the lowest risk for significant long-term urinary tract complications (Stamm, 1975).
There is conflicting evidence over the value of sterile versus nonsterile or “no touch” methods of CIC. Some studies have reported a lower incidence of infection in patients treated with sterile techniques (Foley, 1929), whereas others have not (Pyrah et al, 1955; Nyren et al, 1981). Bennett and coworkers (1997) reported on a sterile method of CIC that uses an introducer tip to bypass the distal 1.5 cm of the urethra and showed a significant decrease in UTI with the use of the urethral introducer tip. Different types of catheters have been used for CIC. The low-friction catheters might be less traumatic for the urethra (Casewell and Phillips, 1977; Garibaldi et al, 1980), but their impact on bacteriuria and UTI has to be studied.
Clinical Presentation
The majority of patients with spinal cord injury with bacteriuria are asymptomatic. Because of a loss of sensation, patients usually do not experience frequency, urgency, or dysuria. More often they complain of flank, back, or abdominal discomfort, leakage between catheterizations, increased spasticity, malaise, lethargy, and/or cloudy, malodorous urine. UTI is the most common cause of fever in spinal cord–injured patients (Beraldo et al, 1993).
Bacteriology and Laboratory Diagnosis
Urinalysis will show bacteriuria and pyuria. Pyuria is not diagnostic of infections, because it may occur from the irritative effects of the catheter. The National Institute on Disability and Rehabilitation Research Consensus Statement (1993) recommended the following criteria for the diagnosis of significant bacteriuria in spinal cord–injured patients. Any detectable bacteria from indwelling or suprapubic catheter aspirates was considered significant because the vast majority of patients with an indwelling catheter and low-level bacteriuria showed an increase to greater than 105 cfu/mL within a short period of time (Cardenas and Hooton, 1995). For patients on CIC, greater than or equal to 102 cfu/mL was considered significant. For catheter-free males, a clean voided specimen showing greater than or equal to 104 cfu/mL was considered significant.
Bacteriuria in patients with spinal cord injury differs from that in patients with intact spinal cords in its etiology, complexity, and antimicrobial susceptibility and is influenced by the type and duration of catheterization. E. coli is isolated in approximately 20% of patients. Enterococci, P. mirabilis, and Pseudomonas are more common among spinal cord–injured patients than patients with intact spinal cords. Other common organisms are Klebsiella species, Serratia species, Staphylococcus, and Candida species. Most bacteriuria in short-term catheterization is of a single organism, whereas patients catheterized for longer than a month will usually demonstrate a polymicrobial flora caused by a wide range of gram-negative and gram-positive bacterial species (Edwards et al, 1983). Such specimens commonly have two to four bacterial species, each at concentrations of 105 cfu/mL or more (Monson and Kunin, 1974; Nickel et al, 1987). Some may have up to six to eight species at that concentration (Monson and Kunin, 1974). This phenomenon is due to an incidence of new episodes of bacteriuria approximately every 2 weeks and the ability of these strains to persist for weeks and months in the catheterized urinary tract (Edwards et al, 1983; Gabriel et al, 1996). Two of the most persistent species are E. coli and Providencia stuartii. P. stuartii is rarely found outside the long-term catheterized urinary tract and may use the catheter itself as a niche (Lindberg et al, 1975; Hockstra, 1999).
Management
Because of the diverse flora and high probability of bacterial resistance, a urine culture must be obtained before initiating empirical therapy. For afebrile patients, an oral fluoroquinolone is the agent of choice (Cardenas and Hooton, 1995). β-Lactams, TMP-SMX, and nitrofurantoin are not recommended because of the high prevalence of bacterial resistance to these drugs. An indwelling catheter should be changed to ensure maximal drainage and eliminate bacterial foci in catheter encrustations. Spinal cord–injured patients with fever or chills are usually admitted and treated with a parenteral aminoglycoside and a penicillin or a third-generation cephalosporin (Cardenas and Hooton, 1995). In this patient population, consultation with a physician with expertise in antimicrobial management may be necessary, especially in a patient with recurrent infections.
If clinical improvement does not occur within 24 to 48 hours, reculture and adjustment of antimicrobial therapy based on the initial culture and susceptibility should be performed. Imaging studies should be obtained to rule out obstruction, stones, and abscess. The duration of therapy is not established, but 4 to 5 days is recommended for the mildly symptomatic patient and 10 to 14 days for sicker patients (Cardenas and Hooton, 1995). Post-therapy cultures are usually not necessary because asymptomatic recolonization is common and not clinically significant. However, if a urea-splitting bacterium is identified, a follow-up culture should be obtained to ensure its eradication. Spinal cord–injured patients with recurrent symptomatic UTIs should undergo urinary tract imaging and urodynamic testing and a review of their bladder management program with particular attention to catheter drainage, intermittent catheterization techniques, and frequency of intermittent catheterization or voiding schedule (Cardenas and Hooton, 1995).
Antimicrobial prophylaxis is not supported for most patients who have neurogenic bladder caused by spinal cord injury (Morton et al, 2002). Antimicrobial prophylaxis did not significantly decrease symptomatic UTIs and resulted in an approximately twofold increase in antimicrobial-resistant bacteria.
Recurrent UTIs may be associated with high storage pressures, and intervention to decrease storage pressure may decrease the incidence of symptomatic UTI. Evidence from studies in spinal cord–injured patients suggests that bladder catheterization for longer than 10 years is associated with an increased risk of carcinoma of the bladder. West and colleagues (1999) examined two databases with more than 33,000 spinal cord–injured patients and identified 130 patients with bladder cancer (0.4%) during a 5-year period. Several risk factors for bladder cancer have been proposed. Vereczky and associates (cited in Weyrauch and Bassett, 1951) tested different risk factors based on the outcome of 153 spinal cord-injured patients in which 7 were diagnosed with bladder cancer. Of a total of 31 possible predictors, only duration of catheterization was significant. Chronic infection and inflammation of the bladder mucosa could be the carcinogenic stimulus in these patients (Pyrah et al, 1955). Nitrosamines produced in infected urine have also been implicated (Najenson et al, 1969).
For further discussion of spinal cord injury and urinary infection, see Chapter 65.
Key Points
Management of UTI in Patients with Spinal Cord Injury
Other Infections
Fournier Gangrene
Fournier gangrene is a potentially life-threatening form of necrotizing fasciitis involving the male genitalia. It is also known as idiopathic gangrene of the scrotum, streptococcal scrotal gangrene, perineal phlegmon, and spontaneous fulminant gangrene of the scrotum (Fournier, 1883, 1884). As originally reported by Baurienne in 1764, and by Fournier in 1883, it was characterized by an abrupt onset of a rapidly fulminating genital gangrene of idiopathic origin in previously healthy young patients that resulted in gangrenous destruction of the genitalia. The disease now differs from these descriptions in that it involves a broader age range, including older patients (Bejanga, 1979; Wolach et al, 1989), follows a more indolent course, and has a less abrupt onset; and, in approximately 95% of the cases, a source can now be identified (Macrea, 1945; Burpee and Edwards, 1972; Kearney and Carling, 1983; Jamieson et al, 1984; Spirnak et al, 1984).
Infection most commonly arises from the skin, urethra, or rectal regions. An association between urethral obstruction associated with strictures and extravasation and instrumentation has been well documented. Predisposing factors include diabetes mellitus, local trauma, paraphimosis, periurethral extravasation or urine, perirectal or perianal infections, and surgery such as circumcision or herniorrhaphy. In cases originating in the genitalia the infecting bacteria probably pass through the Buck fascia of the penis and spread along the dartos fascia of the scrotum and penis, the Colles fascia of the perineum, and the Scarpa fascia of the anterior abdominal wall. In view of the typical foul odor associated with this condition, a major role for anaerobic bacteria is likely. Wound cultures generally yield multiple organisms, implicating anaerobic-aerobic synergy (Meleney, 1933; Miller, 1983; Cohen, 1986). Mixed cultures containing facultative organisms (E. coli, Klebsiella, enterococci) along with anaerobes (Bacteroides, Fusobacterium, Clostridium, microaerophilic streptococci) have been obtained from the lesions.
Clinical Presentation
Patients frequently have a history of recent perineal trauma, instrumentation, urethral stricture associated with sexually transmitted disease, or urethral cutaneous fistula. Pain, rectal bleeding, and a history of anal fissures suggest a rectal source of infection. Dermal sources are suggested by history of acute and chronic infections of the scrotum and spreading recurrent hidradenitis suppurativa or balanitis.
The infection commonly starts as cellulitis adjacent to the portal of entry. Early on, the involved area is swollen, erythematous, and tender as the infection begins to involve the deep fascia. Pain is prominent, and fever and systemic toxicity are marked (Paty and Smith, 1992). The swelling and crepitus of the scrotum quickly increase, and dark purple areas develop and progress to extensive gangrene. If the abdominal wall becomes involved in an obese patient with diabetes, the process can spread very rapidly. Specific genitourinary symptoms associated with the condition include dysuria, urethral discharge, and obstructed voiding. Alterations in mental status, tachypnea, tachycardia, and temperature greater than 38.3° C (101° F) or less than 35.6° C (96° F) suggest gram-negative sepsis.
Laboratory Diagnosis and Radiologic Findings
Anemia occurs secondary to a decreased functioning erythrocyte mass caused by thrombosis and ecchymosis coupled with decreased production secondary to sepsis (Miller, 1983). Elevated serum creatinine levels, hyponatremia, and hypocalcemia are common. Hypocalcemia is believed to be secondary to bacterial lipases that destroy triglycerides and release free fatty acids that chelate calcium in its ionized form.
Because crepitus is often an early finding, a plain film of the abdomen may be helpful in identifying air. Scrotal ultrasonography is also useful in this regard. Biopsy of the base of an ulcer is characterized by superficially intact epidermis, dermal necrosis, and vascular thrombosis and polymorphonuclear leukocyte invasion with subcutaneous tissue necrosis. Stamenkovic and Lew (1984) noted that the use of frozen sections within 21 hours after the onset of symptoms could confirm a diagnosis earlier and lead to early institution of appropriate treatment.
Management
Prompt diagnosis is critical because of the rapidity with which the process can progress. The clinical differentiation of necrotizing fasciitis from cellulitis may be difficult because the initial signs including pain, edema, and erythema are not distinctive. However, the presence of marked systemic toxicity out of proportion to the local finding should alert the clinician. Intravenous hydration and antimicrobial therapy are indicated in preparation for surgical debridement. Antimicrobial regimens include combinations of ampicillin plus sulbactam or a parenteral third-generation cephalosporin such as ceftriaxone, gentamicin, and clindamycin. If there is no response to clindamycin, chloramphenicol may be used.
Immediate debridement is essential. In the patient in whom diagnosis is clearly suspected on clinical grounds (deep pain with patchy areas of surface hypoesthesia or crepitation, or bullae and skin necrosis), direct operative intervention is indicated. Extensive incision should be made through the skin and subcutaneous tissues, going beyond the areas of involvement until normal fascia is found. Necrotic fat and fascia should be excised, and the wound should be left open. A second procedure 24 to 48 hours later is indicated if there is any question about the adequacy of initial debridement. Orchiectomy is almost never required, because the testes have their own blood supply independent of the compromised fascial and cutaneous circulation to the scrotum. Suprapubic diversion should be performed in cases in which urethral trauma or extravasation is suspected. Colostomy should be performed if there is colonic or rectal perforation. Hyperbaric oxygen therapy has shown some promise in shortening hospital stays, increasing wound healing, and decreasing the gangrenous spread when used in conjunction with debridement and antimicrobial agents (Paty and Smith, 1992). Once wound healing is complete, reconstruction, for example, using myocutaneous flaps, improves cosmetic results.
Outcome
The mortality rate averages approximately 20% (Cohen, 1986; Baskin et al, 1990; Clayton et al, 1990) but ranges from 7% to 75%. Higher mortality rates are found in diabetics, alcoholics, and those with colorectal sources of infection who often have a less typical presentation, greater delay in diagnosis, and more widespread extension. Regardless of the presentation, Fournier gangrene is a true urologic emergency that demands early recognition, aggressive treatment with antimicrobial agents, and surgical debridement to reduce morbidity and mortality.
Periurethral Abscess
Periurethral abscess is a life-threatening infection of the male urethra and periurethral tissues. Initially, the area of involvement can be small and localized by Buck fascia. However, when Buck fascia is penetrated there can be extensive necrosis of the subcutaneous tissue and fascia. Fasciitis can spread as far as the buttocks posteriorly and the clavicle superiorly. Rapid diagnosis and treatment are essential to reduce the morbidity and high mortality historically associated with this disease.
Pathogenesis
Periurethral abscess is frequently a sequela of gonorrhea, urethral stricture disease, or urethral catheterization. Frequent instrumentation is also associated with periurethral abscess formation. The source of the infecting organism is the urine. Gram-negative rods, enterococci, and anaerobes are most frequently identified. The presence of multiple organisms is common. Anaerobes, normal residents of the male urethra, are also frequently found in wound cultures.
Clinical Presentation
Presenting signs and symptoms include scrotal swelling in 94% of patients, fever (70%), acute urinary retention (19%), spontaneously drained abscess (11%), and dysuria or urethral discharge (5% to 8%). The average interval between initial symptoms and presentation is 21 days. Urinalysis of the first glass specimen reveals pyuria and bacteriuria.
Management
Treatment consists of immediate suprapubic urinary drainage and wide debridement. Antimicrobial therapy with an aminoglycoside and a cephalosporin is usually adequate for empirical coverage. More selective antimicrobial therapy can be instituted when the antimicrobial susceptibility of the organisms is available. Perineal urethrostomy or chronic suprapubic diversion occasionally has been helpful to prevent recurrences, and it should be considered in patients with diffuse stricture disease. The presence of a malignancy is unusual, but biopsy is important.
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