Urinary Tract Infection in Spinal Cord Transected War Victims
Siavash Falahatkar MD, Abdol-Rasoul Sobhani MD, Hani Gholipour MD, Kamran Ghaneh MD
Department of Urology, Gilan University of Medical Sciences, Rasht, Iran
Background- Injury to the spinal cord can
lead to dysfunction of the urinary system, which in turn
leads to an increased risk for the development of
conditions such as urinary tract infection (UTI) and
stones, vesicoureteral reflux, bladder diverticula,
increased urinary residue, urinary obstruction and renal
failure.
Methods-This study was conducted on 50
spinal cord transected war victims of Gilan province,
north of Iran. Complete laboratory tests, including urine
culture and antibiogram were performed for all patients.
Results- Out of the 50 patients in our
study, 23 (46%) were found to have UTI (54%). The average
age of the UTI and the non-UTI patients was 35.9 and 36
years respectively and the average period since the
spinal cord transection was 14 years in the UTI and 13.5
years in non-UTI patients. E. coli
was the most common organism resistant to routine drugs.
Maximum resistance existed towards ceftizoxime (84.6%),
kanamycin (84.7%), and Co-trimoxazole (92%) and least
resistance towards cephalothin (15.2%) and amoxicillin
(15.2%).
Conclusion-Our study shows that a
considerable number (88%) of the patients had some form
of drug resistance which is probably due to the
indiscriminate use of antibiotics in war victims. It is recommended to treat spinal cord
transected war victims suffering from UTI, with the more
available and cheaper antimicrobials such as cephalothin
and amoxicillin in the first line and resort to more
costly antimicrobials for special cases.
Keywords • Urinary tract infection • spinal cord injury • cord transection
Introduction
Trauma to the vertebral column can cause injury to the spinal cord as well as to the nerve roots originating from it which in turn leads to dysfunction of various organs supplied by these nerves.
Spinal cord injury may result from indirect forces which is brought about mainly by the destruction of neighboring vertebra due to bullet or mortar-shell impaction.1-4
One of the important abnormalities seen in the spinal cord transected patients is urinary bladder dysfunction.3 Complications mostly found in these patients include UTI, hydronephrosis, urinary tract stones, vesicoureteral reflux, bladder diverticula, urinary tract obstruction, incomplete emptying of bladder, and renal failure.3,4,7
Urinary tract infection mainly results from abnormalities such as urinary bladder dysfunction or neurogenic bladder.3,5,6 Vesicoureteral reflux, urinary tract stones, urinary obstruction, incomplete emptying of the bladder (increased urinary residue) and the use of urinary catheter act as precipitating factors in UTI.2
In spinal cord transected patients, UTI is mostly of multimicrobial etiology. E. coli, Klebsiella, Pseudomonas cytobacteria and Staphylococci are the most common pathogens encountered.
It must be noted that the classical symptoms of UTI may not be seen in cases of neurogenic bladder and most cases are asymptomatic. It may also be difficult to distinguish UTI from neurogenic bladder.
Materials and Methods
This cross-sectional study was conducted in Gilan province on a population of 50 spinal cord transected war victims who had developed spinal cord transection during the war (between October 1980 and October 1989). Diagnosis of spinal cord transection was established by a neurosurgeon.
Specimens of urine were collected from all patients and a complete (urologic) clinical examination as well as necessary paraclinical investigations were conducted for all patients. Urinalysis, culture and antibiogram were performed and microbial resistance was determined for each patient.
Any accompanying urologic disease was diagnosed by abdominal X-ray, ultrasonography and voiding cystourethrogram (VCUG). Past history of urologic surgery was noted. The diagnosis of neurogenic bladder was based on radiographic, hemodynamic and cystoscopic findings. Residual urine of more than 30 ml was considered of importance. Drug resistance was also determined using the antibiogram.
Results
Twenty-three (46%) of the total 50 war victims with spinal cord transection suffered from UTI, and the remaining 27 (54%) had sterile urine.
The average age of the UTI patients was 35.9 years with the lowest and highest ages being 31 and 51 years respectively.
The average period since spinal cord transection in UTI patients was 14 years and in the non-UTI patients it was found to be 13.5 years.
Table 1 shows the frequency of the concomitant urologic diseases in both UTI as well as non-UTI patients. Out of the 23 UTI patients, 22 (88%) showed antibiotic resistance, which was mainly detected in UTIs caused by E. coli. Table 2 shows the frequency of antibiotic resistance in E. coli infection. The highest resistance was present to ceftizoxime (84.7%), kanamycin (84.7%) and cotrimoxazole (92%) and the lowest resistance was seen to cephalothin (15.2%) and amoxicillin (15.2%). All isolated Proteus species showed resistance towards ampicillin, kanamycin, nitrofurantoin and nalidixic acid. Also all isolated Kelebsiella species were resistant to ampicillin, kanamycin, cotrimoxazole and nalidixic acid.
Discussion
UTI is the most common complication of spinal cord injury and about half of the spinal cord transected war victims suffer from UTI. This in turn can lead to renal failure and infertility in men.1, 2
E. coli is the leading cause of UTI (70% of cases) 4-6 and is resistant to many antibiotics, namely cotrimoxazole (92%) kanamycin (84%), ceftizoxime (84%), gentamycine (23%), cephalothin (15.2%) and amoxicillin (15.2%). It is, therefore, suggested that for the treatment of UTI in spinal cord transected war victims, antimicrobials having minimum resistance such as amoxicillin and cephalothin be used first. Apparently injudicious use of more expensive, second and third line antimicrobials, with the intention of facilitating the rapid resolution of infection, in cord transected war veterans has led to resistance to these agents. Interestingly, more abundant and routine antimicrobials have remained more effective.
Of the 23 spinal cord transected patients suffering from UTI, 5 (22%) had urinary tract stones which was not significantly different from the non-UTI group. However, 9 (18%) of the total 50 war victims in our study had urinary tract stones which shows a higher prevalence rate (2-3%) than the normal population. 3
We recommend to these patients to increase their physical activity and fluid intake in order to prevent the formation of urinary tract stones and to have frequent urine analysis and urine culture performed, thereby limiting the need for antimicrobials.
Our study was conducted on a limited number of patients. We, therefore, propose to perform extended studies with closer scrutiny on the relevant aspects of neurogenic bladder.
References