Discussion & Conclusion A RETROSPECTIVE ANALYSIS OF SYMPTOMATIC UTI ASSOCIATED WITH CIC AMONG SPINAL CORD INJURY PATIENTS Sharma S, Banerjee P, Vijay D, Haokip H Department of Hospital infection Control, Indian Spinal Injuries Centre, Sector C , Vasant Kunj, New Delhi - 110070 Introduction Observations (contd.) Spinal cord injury (SCI) leads to neurogenic bladder defined as abnormal function of urinary bladder secondary to any neurologic condition of the central nervous system or peripheral nerves involved in the control of micturition. Bladder management to maintain adequate bladder drainage with low pressure urine storage & voiding becomes essential in such patients for preventing urinary tract complications including urinary tract infection (UTI). UTI in SCI patients occurs due to bladder over distention, outlet obstruction, detrusor-sphincter dyssynergia, increased intravesical pressure, vesicoureteral reflux, and large post-void residual urine volume. Various methods for bladder management in these patients are available including: Clean intermittent catheterization (CIC), Indwelling catheters (urethral or suprapubic), condom catheters, Sphincterotomy, Ileovesicostomy, creation of continent catheterizable stoma & bladder augmentation and Ileal conduit. CIC is a commonly preferred option for long term bladder management among SCI patients. However, researchers studying the effectiveness of CIC procedure have reported some complications in patients performing the procedure, including UTI, trauma to lower tract, prostatitis, urethral strictures & false passages, epididymitis and urethritis. The percentage of SCI patients on CIC developing UTI ranged from 5.4% to 13.5% (on an average 9.3%) per month. The number of CIC-UTI cases ranged from 2 to 5 (on an average 4) per month, accounting for an average CIC-UTI rate of 4.5 per 1000 patient days. CIC-UTI cases were distributed evenly in all months throughout the year with no seasonal preponderance. Among the subjects developing UTI (n=40), 33 became symptomatic for UTI during self CIC period. The time interval between initiation of CIC procedure & symptomatic UTI episode was less than 10 days in only 7 (21%) subjects. The predominant pathogen isolated in CIC-UTI cases included Gram negative bacteria ie, Klebsiella pneumoniae (17 isolates, 37%), Escherichia coli (15 isolates, 33%), Pseudomonas aeruginosa (5 isolates, 11%). Of the 46 pathogenic isolates in CIC-UTI cases, 23 (50%) strains were multi-drug resistant including resistance to carbapenems. Purpose of the study The study was aimed to investigate the association of symptomatic urinary tract infections with the use of clean intermittent catheterization for the management of neurogenic bladder in patients with spinal cord injury Methods The study was conducted among SCI patients with neurogenic bladder admitted from August 2014 to July 2015 in Indian Spinal Injuries Centre. Inclusion criteria for the study were: neurogenic bladder dysfunction, stable traumatic SCI, bladder management with CIC. Exclusion criteria were: other etiology (other than SCI) for neurogenic bladder, other methods of bladder management (including other catheterization methods). A total of 882 subjects were included in the study based on inclusion criteria. Clinical records of these patients were retrospectively reviewed for demographic & clinical details of patients and laboratory test (including urine microscopy & culture) results. The entire protocol for introducing CIC method for bladder management in each subject was as follows: Following admission, the patient was briefed by urology counselor on the importance of CIC as a relatively easy , effective & safe method of bladder management. For the initial 2 days, CIC was performed in these individuals by health care staff of ISIC. The procedure was performed at an interval of four hours. Following this, a complete training session was given to the patient and his/her care givers on CIC emphasizing upon the importance of CIC & its possible complications, demonstration of the correct method of performing the procedure including all the infection prevention measures to be taken while performing it. The patient or caregivers were allowed to perform CIC independently under supervision of healthcare staff for next 2 days and then allowed to continue unsupervised following satisfactory performance. The urology counselors interacted with the patient & caregivers thrice per week during the rest of the hospital stay of the patient to guide them further. Presence of UTI in the subjects was clinically suspected by any 1 or more of these: vague back or belly discomfort, leakage between catheterizations, increased spasticity, cloudy urine with increased odor, autonomic dysreflexia, fevers, decreased appetite, or lethargy. Laboratory diagnosis of UTI was based upon ‘The National Institute on Disability and Rehabilitation Research’ definition of UTI as the presence of significant bacteriuria (more than 103 cfu/mL) with tissue invasion and resultant tissue response with signs and/or symptoms of UTI. The subjects developing symptoms of UTI, unattributable to other causes, after a minimum interval of 48 hours of starting CIC procedure along with significant growth of pathogens in urine culture were finally diagnosed as CIC-associated UTI. Discussion & Conclusion CIC is a common bladder catheterization method used in the years following SCI. Some studies looking at the effectiveness of CIC have observed an increased frequency of UTIs, raising the need for prophylactic antibiotics. In our study 40 (4.5%) patients developed CIC-UTI. Wyndaele et al reported that 53% patients on CIC develop UTI. In present study our average CIC-UTI rate was 4.5 per 1000 patient days. Rhame & Perkash reported CIC-UTI rate of 10.3 per 1000 patient-days in SCI patients while Singh R et al from India reported an incidence of UTI in SCI patients on CIC as 0.34 per 100 person-days. Among the pathogen isolated in CIC-UTI cases, majority were Gram negative organisms , of which 50% strains were resistant to multiple antibiotics including carbapenems. The percentage of carbapenem resistant strains of Gram negative bacteria isolated from clinical samples in ISIC during same period was 41.5%. Togan T et al reported from Turkey, 100% sensitivity to carbapenems for their isolates. Not much data is available from India on sensitivity pattern of uropathogen in CIC-UTI cases. Although our study shows low incidence of CIC-UTI, over 80% patients developed CIC-UTI after 10 days of starting CIC by self or caregivers. This is in concordance with Wyndaele et al that if CIC is done by patient him/her self or trained healthcare worker, reduced rates of CIC-UTIs are observed. This shows the need to further evaluate patient/attendant educational and socio-economic status to strengthen their training with respect to appropriate technique and infection prevention measures during CIC in this niche population. Also equal emphasis should be given to antibiotic stewardship programs to reduce the incidence & spread of Multi-drug resistant organisms (MDROs) in the hospitals. Observations References The total number of subjects included in the study was 882. In the entire period of the study, 46 (5.1%) episodes of CIC associated UTI (CIC-UTI) based upon clinical & laboratory diagnosis, were observed. Repeat episodes of symptomatic UTI were observed in 6 patients, out of which 5 episodes of recurrent UTI occurred in successive months. CIC associated UTI, occurred in 6 female and 40 male subjects. The cases of CIC-UTI were evenly distributed in different age groups: 21 episodes in 16-25 year age group, 16 episodes in 26-50 age group and 19 episodes in 51-75 year age group respectively. None of the cases belonged to pediatric age group. Edokpolo LU, Stavris KB, Foster HE. Jr. Intermittent catheterization and recurrent urinary tract infection in spinal cord injury. Top spinal cord Inj. Rehabil.2012 Spring;18(2): 187-192.doi:10.1310/sci1802-187 Togan T, Azap OK, Durukan E et al. The prevalence, etiologic agents and risk factors for urinary tract infection among spinal cord injury patients. Jundishapur J. Microbiol. 2014;7(1):e8905 Wyndaele JJ. 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