Multifaceted Treatment of Catheter-related Urinary Tract Infection

UTI is the most common infection in patients with spinal cord injury who require a catheter
to drain urine from their bladder. These infections can cause serious medical
complications, such as bloodstream infection, decreased kidney function, prolonged
hospitalization, and add great cost. Unfortunately, the treatment of catheter-related
urinary tract infection has not been standardized in this population in terms of:

- the need to replace the indwelling catheter;

- the necessity to provide antibiotic coverage against all organisms grown from urine
cultures; and

- the duration of antibiotic treatment.

The prevalent, though not scientifically well supported approach for treating
catheter-related lower UTI in patients with spinal cord injury comprises
the following:

- Retaining the original bladder catheter in place upon diagnosis of infection because of
the theoretical concern that removal of the infected catheter may potentially cause the
infecting organism to move from the bladder to the bloodstream (bacteremia). This
theoretical complication, however, is very unlikely and even if it does occur, the
bacteria would only remain in the bloodstream for a very short period of time and would
not have a significant impact on the patient. In contrast, we propose that immediate
removal of the original indwelling bladder catheter with its film of protected bacteria
can enhance resolution of UTI.

- Providing antibiotic coverage against all organisms which grow from a urine culture
that is obtained from the original indwelling bladder catheter. Although this source of
urine culture is a sensitive method for identifying the organisms that are present in
the urine, it suffers from poor specificity because it may yield the growth of some
organisms that could have colonized the catheter (and, therefore, grown in a culture of
urine obtained through that original catheter) but did not contribute to UTI. This
issue is particularly problematic in patients with spinal cord injury because urine
cultures in almost half of the cases of UTI in this population yield multiple bacteria.
Therefore, we propose that collection of a urine culture while inserting the new
bladder catheter would yield growth of only organisms that truly contribute to UTI and,
therefore, obviate the need to administer unnecessary antibiotics to cover additional
organisms that would grow only from urine cultures obtained through the original
catheter.

- Treatment with systemic antibiotics for 10 days. There exists, however, no prospective
randomized clinical trials indicating that this duration of antibiotic therapy is
optimal in patients with spinal cord injury. Since catheter-free, able-bodied patients
with lower UTI are successfully treated with courses of antibiotics as short as 1-3
days, we propose that by removing the focus of infection (i.e. the original catheter) a
5-day course of systemic antibiotics would be sufficient for treating catheter-related
lower UTI in patients with spinal cord injury.

The results of this research are expected to provide the following major benefits to
veterans with spinal cord injury:

- the multifaceted approach will provide highly effective treatment of UTI;

- the lower number of antibiotics that are administered to cover the organisms grown from
urine cultures obtained at the time of inserting the replacement bladder catheter will
result in lower cost of treatment and a reduced risk for developing antibiotic
resistance;

- the shorter duration of antibiotic course will decrease the overall cost of treatment,
reduce hospital stay, and shorten rehabilitation down time.

Inclusion Criteria:

- Adult patients with SCI who are hospitalized at the Michael E. Debakey VA Medical
Center and suffer from lower UTI associate with an indwelling transurethral or
suprapubic bladder catheter will be enrolled in the study

Exclusion Criteria:

- Exclusion criteria will include septicemia, chronic antimicrobial therapy and
inability, or unwillingness to give informed consent