How to manage and prevent urinary tract infections in neuropathic bladder

1. How to manage and prevent urinary tract infections in neuropathic bladder Department of Urology, St. Vincent’s Hospital The Catholic University of Korea, College of Medicine 하 유 신

2. Chronic or recurrent urinary tract infection with neurogenic bladder dysfunction High morbidity, frequent hospitalization, costs Nosocomialinfection, in itself Renal insufficiency What is the optimal management?

3. Predisposing factors Structural/physiological factors overdistension of the bladder high-pressure voiding large PVR stone outlet obstruction ex. BPH, urethral stricture, DSD Behavioral factors patient’s knowledge personal hygiene social support systems age, gender

4. Structural/physiological factors Detrusor overactivity Detrusor sphincter dyssynegia

5. Structural/physiological factors VUR Frequent catheterization

6. Structural/physiological factors DSD, BOO, Stricture Detrusor overactivity High residual V High pressure storage High detrusor leak P. Intravesical pressure Infection VUR VUR Renal damage

7. Behavioral factors Have not been so well studied patient’s knowledge of the urinary system personal hygiene adjustment to disability social support systems age gender May have association with UTI

8. Method of urinary drainage • indwelling urethral cath. – 100% by day 4 c open system 20% by day 15 c closed system 85-95% thereafter • incidence of UTI Stamm ; Am J Med 1991 Perkash ; Urol North Am 1993 Indwellng urethral cath. – important risk factor Esclarin et al ; J Urol 1991 King et al ; Arch Phys Med Rehabil1992

9. Study of catheter free outpatients • poor personal hygiene • ethnicity • less-than daily condom cath. changes • bladder drainage method (CIC vs condom cath.) • age • gender • neurological injury level Waites et al ; Arch Phys Med Rehabil 2000 Correlation with UTI Not correlation

10. Clinical symptoms and Diagnosis Typical manifestations of symptomatic UTI • frequency, dysuria ; early Sx. • usually absent in patients c neurogenic bladder dysfunction May be delayed or missed • Fever • Discomfort • Incontinence • Increased spaciticity • Autonomic hyperreflexia Suggestive of UTI

11. Diagnosis for UTI Controversy, difficult and comprehensive consideration

12. Diagnostic criteria for UTI Stover et al ; Arch Phys Med Rehabil 1989

13. National institure on Disability and Rehabilitation Research ; 1992

14. National institure on Disability and Rehabilitation Research ; 1992 Today, we don’t have the exact method to determine if tissue invasion has occurred or not

15. Management When to treat • colonization, asymptomatic bacteriuria, symptomatic bacteriuria Which antibiotics to choice • Empirical therapy • Susceptibility based choice • Area-specific surveillance Management of predisposing factor

16. When to treat ? ? Cardenas & Hooton ; Arch Phys Med Rehabil 1995

17. To evaluate the microbial efficacy of antimicrobial Tx • 64 cath.-free spinal cord injury pt • asymptomatic pt Waites et al ; paraplegia 1993 <<

18. Asymptomatic bacteriuria will lead to symptomatic infection and renal damage ? • 14 neurogenic bladder c CIC • asymptomatic bacteriuria pt • total 323 observed patient wks • only 5 symptomatic infections Schlager et al ; J Ped 1995 Bacteriuria persist for weeks in symptom and renal damage free state

19. When to treat

20. Biering-Sorenen et al ; Drugs 2001 Fluoroquinolone, aminopenicillin c BLI, 2nd or 3rd cephalosporin in complicated UTIs d/t urological disorders EAU guideline ; 2006 Which antibiotics to choice Sauerwein ;IJAA 2002 Biering-Sorenen et al ; Drugs 2001

21. Which antibiotics to choice Warren et al ; Clin Infect Dis 1999 EAU guideline ; 2006

22. Int J Antimicrob Agents In Press

25. Int J Antimicrob Agents In Press

26. DSD, BOO, Stricture Detrusor overactivity High detrusor leak P. High pressure storage High residual V High detrusor leak P. Infection VUR VUR Renal damage Management of predisposing factor High pressure bladder Insufficient emptying Stable bladder Low storage pressure Low Detrusor leak pressure Effective bladder emptying

27. Prevention General Antiseptic and antibacterials agents • Topical administration • Antiseptic solution • Urine pH • Prophylactic antibiotics Novel indwelling catheter • Biofilm • Silver-coated catheter • Hydrogel-coated catheter • Antibiotic-coated catheter

28. General

29. Antiseptic and antibacterials agents No clinical benefit Kevorkian ; Mayo Clinic Proc 1984 Krebs ; J Urol 1985 Castello et al ; Spinal cord 1996

31. Prevention Novel indwelling catheters • ascending colonization within biofilm • mechanical barrier • Protecting bacteria • Resistant to antibiotics • The central factor Seek to alter the catheter surface in order to inhibit biofilm formation !!

32. Novel indwelling catheters

33. Silicone cath. Nitrofurazone coated Effective during short term No advantage during long term Scanning EM of the catheter surface from patients catheterized for 7 days SJ Lee et al ; Int J Antimicrob Agents 2004

34. CONCLUSION Symptoms and Diagnosis Subtle, may be delayed or missed Different mirobiological criteria Optimal management Administration antibiotics to only symptomatic UTI Empirical Tx ; based on area-specific surveillance Evaluation & management of predisposing factor Prevention Keep general basic principle