Urine culture and sensitivity profile in patients with traumatic spinal cord injury

Chinzah Zonunsanga; Asem Rangita Chanu; Hmingthan Mawii; Minggam Pertin; Nongmaithem Romi Singh

doi:10.4103/0972-4958.121576

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ORIGINAL ARTICLE

Year : 2013 | Volume : 27 | Issue : 2 | Page : 106-109

Urine culture and sensitivity profile in patients with traumatic spinal cord injury

Chinzah Zonunsanga, Asem Rangita Chanu, Hmingthan Mawii, Minggam Pertin, Nongmaithem Romi Singh
Department of Physical Medicine and Rehabilitation, Regional Institute of Medical Sciences, Imphal, Manipur, India

Date of Web Publication

19-Nov-2013

Correspondence Address:
Nongmaithem Romi Singh
Department of Physical Medicine and Rehabilitation, Regional Institute of Medical Sciences, Imphal - 795 004, Manipur
India

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/0972-4958.121576

Abstract

Objectives: To determine the urine culture and sensitivity profile in traumatic spinal cord injury (SCI) patients during admission in Physical Medicine and Rehabilitation setting in a tertiary care hospital. Study Design: A retrospective descriptive study. Setting: Department of Physical Medicine and Rehabilitation, Regional Institute of Medical Sciences, Imphal. Study Duration: January 1, 2012 to December 31, 2012. Materials and Methods: All the traumatic SCI patients admitted in the department and whose urine samples were sent for culture and sensitivity were included in the study. There were a total of 18 patients. Urine culture revealing a bacterial colony count of 10 ⁵ colony forming units (cfu)/ml was taken as significant bacteriuria. Results: Of all 18 patients, 15 (83.3%) patients had significant bacteriuria showing only gram-negative bacteria and three (16.6%) patients had sterile urine. All the positive urine samples showed growth of only single bacteria except in one (5.5%) patient. The most common organism isolated was Escherichia coli which was found in ten (55.5%) urine samples This was followed by one (5.5%) each for Klebsiella, Pseudomonas, Providencia, Enterobacter and one with combination of Klebsiella with Pseudomonas. Amikacin and nitrofurantoin were the most sentitive antibiotics encountered in majority of the gram-negative isolates. All the organisms were sensitive to imipenem. Conclusion: Only gram-negative bacteria were isolated from the urine samples of traumatic SCI inpatients with E. coli as the most common organism. Amikacin and nitrofurantoin were the most common sensitive antibiotics.

Keywords: Antibiogram, Significant bacteriuria, Traumatic spinal cord injury, Urine culture and sensitivity

How to cite this article:
Zonunsanga C, Chanu AR, Mawii H, Pertin M, Singh NR. Urine culture and sensitivity profile in patients with traumatic spinal cord injury. J Med Soc 2013;27:106-9

How to cite this URL:
Zonunsanga C, Chanu AR, Mawii H, Pertin M, Singh NR. Urine culture and sensitivity profile in patients with traumatic spinal cord injury. J Med Soc [serial online] 2013 [cited 2023 Mar 27];27:106-9. Available from: https://www.jmedsoc.org/text.asp?2013/27/2/106/121576

Introduction

Urinary tract infection (UTI) is the single most frequent, secondary medical complication in persons with spinal cord injury (SCI).[1] The diagnosis of UTI is usually made based on the presence of signs and symptoms and confirmed by culture examination with significant bacteriuria supported by high level pyuria. Typical manifestations of symptomatic UTI are typically absent in SCI patients with neurogenic bladder dysfunction and impaired sensation. The diagnosis of UTI in SCI patients may be delayed or missed, because symptoms are often subtle.[2] Signs and symptoms of UTI in SCI patients include fever, discomfort or pain over the loin or lower abdomen, urinary incontinence, increased spasticity, autonomic hyperreflexia, cloudy urine with increased odor, malaise, or lethargy.[3] SCI having neurogenic bladder is at the risk of UTI for several reasons such as bladder distension, elevated detrusor pressure which cause loss of immunity and decreased wall movement, impaired bladder emptying, repeated instrumentation, vesicoureteric reflux, and indwelling urinary catheters.[4] UTI is common in all SCI irrespective of the type of bladder management used, intermittent clean catheterization (ICC) has become a mainstay in the care of patients with SCI, mainly because of evidence that it decreases the incidence of UTI and urologic complications.[5] UTI in neurogenic bladder can result in epididymitis, orchitis, penoscrotal abscess, penoscrotal fistula, and bladder stones. This can also complicate upper urinary tract and result in pyelonephritis, hydronephrosis, renal stones, renal scarring, and renal function deterioration which can cause chronic renal failure.[6] Studies of the long-term use of antibiotic for patients with SCI have reported a predictable increase in antimicrobial resistance and adverse drug reactions.[7] Studying the local spectrum and sensitivity of causative organisms and characterizing safest mode of drainage will not only help in reducing the disease burden but also ensure prompt and early rehabilitation.

Objectives

To determine the antibiotic sensitivity of urine amongst traumatic SCI inpatients during admission in Physical Medicine and Rehabilitation, Regional Institute of Medical Sciences, Imphal.

Materials and Methods

Study Design

It is a retrospective study undertaken in the department of Physical Medicine and Rehabilitation, Regional Institute of Medical Sciences, Imphal during the period from January 1, 2012 to December 31, 2012. All the traumatic SCI inpatients whose urine samples were sent for culture and sensitivity during admission were included in the study. There were a total of 18 such patients. Urine culture revealing a bacterial colony count of 105 colony forming units (cfu)/ml was taken as significant bacteriuria.

Exclusion Criteria

Patients receiving any type of antibiotic or immunosuppressive therapy or suffering from immune deficiency disorders were excluded to avoid the bias of susceptibility to infection and thus also nontraumatic SCI patients were excluded to make a homogenousity of the study population.

Data Collection Procedure

Hospital files of Traumatic SCI patients admitted for rehabilitation from January 1, 2012 to December 31, 2012 were reviewed retrospectively. Only the data of first admission to our hospital were included in the study. Demographics, etiological factors, level of injury as per American Spinal Injury Association (ASIA) Impairment Scale, urine culture, and sensitivity reports sent at the time of admission were taken into account in the present study. Complications related with SCI were also noted.

In our set up, majority of SCI patients usually reported to us with indwelling catheter as mode of bladder emptying after the SCI. As soon as acute resuscitation and polytrauma management (if any) was over, we preferably changed to ICC as preferred mode of bladder emptying if the urine culture is sterile at least subclinically. At the time of admission, urine sample was sent for culture and sensitivity and a course of sensitive antibiotic was started (if indicated) before switching over to ICC.

Urine culture revealing a bacterial colony count of 105 cfu/ml was taken as significant bacteriuria. Susceptibility testing was performed for only those organisms found significant.

Statistical Analysis

Statistical analysis was conducted using SPSS version 17.0. Frequencies and percentages were calculated.

Results

The demographic profile of the patients, nature of injury, and duration and type of SCI is given in [Table 1].

Table 1: Showing demographic profile, nature of injury, and duration and types of SCI

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Of all 18 patients, 15 (83.3%) patients had significant bacteriuria showing only gram-negative bacteria and three (16.6%) patients had sterile urine.

All the positive urine samples showed growth of only single bacteria except in one (5.5%) patient. The commonest organism isolated was Escherichia ^{More Details} coli, found in 10 (55.5%) urine samples. This was followed by one (5.5%) each for Klebsiella, Pseudomonas, and Providencia, Enterobacter and one with combination of Klebsiella with Pseudomonas as shown in [Table 2].

Table 2: Showing organisms isolated from urine

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The antibiotic sensitivity pattern is shown in [Table 3]. The most common organism isolated, that is, E. coli was found to be sensitive to amikacin and nitrofurantoin in 70 and 80% of the cases, respectively. Other gram-negative isolates like Klebsiella, Enterobacter, Pseudomonas, etc. were found to be highly sensitive to amikacin and nitrofurantoin. All the organisms were 100% sensitive to imipenem.

Table 3: Showing antibiotic sensitivity pattern of isolates

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ICC was done in 14 patients, self-voiding (Valsalva maneuver) in three patients, and suprapubic catheterization in one patient (due to penoscrotal fistula).

Discussion

The annual worldwide incidence of SCI is approximately 40 per million. Asymptomatic bacteriuria is common (70%) in SCI patients under catheterization, with UTI being the most frequent complication. It is still one of the leading causes of morbidity in SCI.[8] Whiteneck et al.,[9] retrospectively noted that annual incidence of UTI in SCI is 20%.

The method of urinary drainage is an important risk factor for UTI. The use of an indwelling urinary catheterization (IUC) is the most common cause; the presence of bacteriuria was 100% by fourth day with IUC with open collecting systems, 50% by 15th day with closed collecting systems, and 85-95% thereafter.[10],[11],[12] Other drainage methods, such as ICC and condom catheter, reduce the incidence of UTI (0.31 and 0.46 episodes/100 person days, respectively).[5],[13],[14] These rates support the observation that ICC and condom catheter are reasonable means of managing neurogenic bladder dysfunction in SCI. In our study, 14 patients (73.3%) were put on ICC as early as possible and the remaining patients were on self-voiding technique except one patient on suprapubic catheterization which was due to penoscrotal fistula as a complication of prolonged indwelling catheterization.

In this study, 83.3% patients showed significant bacteriuria and all showed growth of a single organism except in one (5.5%) case. This finding is in line with the study of Ryu et al.,[15] which also found 74.8% cases with significant bacteriuria and 30.2% of them showed growth of more than a single bacteria.

Because of loss of sensation, patients with SCIs do not have common symptoms of UTI such as frequency, urgency, and dysuria. The clinical features of UTI may include fever, pyuria, and other ''soft'' signs and symptoms such as discomfort over the back or abdomen during urination, onset of incontinence, increased spasticity, autonomic hyperreflexia, malaise, lethargy, or observation of cloudy urine with increased odor.[16]

Gram-negative bacteria were the only organism isolated in our study. These organisms were the commonest causative organisms as found in 84% cases by Ryu et al.,[15] In contrast to our study, Ryu et al.,[15] found gram-positive organisms in 13.6% cases. This might be probably explained by the fact that their study included repeated samples following follow-up visits, which was found to be associated with the growth of polymicroorganisms including gram-positive isolates. Previous authors also observed that E. coli is the most common cause of UTI in SCI patients.[15],[16],[17],[18] The present findings also observed E. coli as the most common organism isolated from the urinary samples of SCI patients.

Asymptomatic bacteriuria need not be treated with antibiotics. Symptomatic UTI warrants therapy in all patients.[18] Prolonged or repeated exposure to antimicrobial agents and consequent antibiotic prescription increases the risk of colonization and infection with multiresistant bacteria. Waites et al.,[19] showed that 33% of isolates from SCI outpatients were multiresistant organisms. In the present study, amikacin and nitrofurantoin were found to be sensitive to 70-80% of E. coli and rest of gram-negative bacteria except Providencia which was only sensitive to imipenem. We found similar cases of multiresistant organisms as highlighted by other authors. Even though all the gram-negative bacteria were found to be sensitive to imipenem, its routine use as an empirical therapy is still difficult because of cost factors and being the latest generation cephalosporin which may be preferably reserved for last resort in view of common feature of antibiotic resistance to organisms in hospital set up.

Since chronic and recurrent infection is more prevalent in SCI patients, we need to know about local bacterial spectrum and sensitivity to device empirical antibiotic therapy to start the treatment before the results of urinary culture and sensitivity report is available to shorten treatment time and costs.

ICC has become a mainstay of urinary drainage in the care of patients with SCI, mainly because of evidence that it decreases the incidence of UTI and urologic complications. ICC is encouraged as the choice of urinary drainage for those SCI patients with adequate hand function or a willing healthcare provider.

Limitations

Small sample size and retrospective study.
Short duration of the study.
Significant bacteriuria as urine culture revealing a bacterial colony count of 105 cfu/ml, and not National Institute on Disability and Rehabilitation (NIDRR) congress conference recommendations of ?102 cfu/ml for ICC; ?104 cfu/ml for clean void specimens from catheter-free males using condom collecting devices; and any detectable concentration of uropathogens from indwelling catheters or suprapubic aspirates.[18]

Conclusion

UTI is common among traumatic SCI patients at the time of admission in our setting. Only gram-negative bacteria were isolated from the urine samples of SCI patients, with E. coli as the most common organism. Routine prophylaxis of UTI is not recommended, but it is preferred to optimize bladder drainage methods and treat only those patients with symptomatic UTI or those patients with significant bacteriuria with treatment lasting for at least 10-14 days. Considering the high level of UTI during admission amongst these patients, empirical treatment with the antibiotic which is most commonly susceptible to common gram-negative isolate can be tried in patients who are suffering from signs and symptoms of UTI. Therapy, then can be modified when the infecting strain has been identified and antimicrobial susceptibilities known. The results of our study can be used as a guideline for future studies in this part of the country to come to best suitable empirical drug therapy. Knowing the local spectrum and sensitivity of causative organisms will not only help in reducing the disease burden, but also ensure prompt and early rehabilitation.

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