URINARY TRACT INFECTION AND NEUROGENIC BLADDER (NGB)

URINARY TRACT INFECTION AND NEUROGENIC BLADDER (NGB)

1. INTRODUCTION

   • micturition
     • requires function of
       • bladder
       • urethral sphincter complex
       • this process
         • is coordinated by
           • central nervous system
           • peripheral nervous system
           • disruption here
             • caused by
               • diseases
               • damage
                 • interferes
                   • with coordinated effort
                     • neurogenic bladder
                       • abnormal storage
                       • abnormal emptying
                       • improper management
                         • renal injury
                         • renal failure
                         • pyelonephritis
                           • kidney deterioration

2. EPIDEMIOLOGY

   • estimates NGB in USA
     • approximately
       • 400,000 people
         • are diagnosed with
           • spina bifida
             • UTI
               • most common
                 • in emergency room
           • spinal cord injury
             • 31% were diagnosed
               • first year
                 • 21% = hospitalization
             • 2.5 symptomatic UTI
               • per year
           • cerebral palsy
           • multiple esclerosis
           • parkinson disease
   • increased
     • frequency and severity of
       • higher risk of
         • morbidity
         • mortality
         • secondary to
           • urosepsis
           • end-stage renal disease

3. PATHOGENESIS

   • bladder dysfunction
     • abnormal urodynamic parameters
       • in patients with NGB
         • increased rick of UTI
     • detrusor overactivity
       • decreased
         • bladder compliance
     • vesicoureteral reflux
       • febrile UTI
         • spinal dysraphism
     • increased intravesical pressure
       • bladder ischemia
         • delayed or deficient
           • inmune response to pathogen
       • in
         • distendent
         • empty
           • bladder
             • suggest dysfunction
   • URINARY STASIS / INCREASED POSTVOID RESIDUAL
     • normal voiding
       • protects against UTI
         • 99.9% of bacteria are removed by voiding
     • inefficient voiding
       • with residual urine
         • development of UTI
     • association between
       • PVR urine / UTI
         • among patients with spinal cord injury and NGB
           • PVR > 300 mL
             • 4 to 5 times more UTI
     • 2 studies of patients
       • after stroke
         • PVR after 150 mL
           • risk factor
             • UTI
         • PVR after 100 mL
           • 4.9 - fold increased
             • UTI
             • from those with
               • PVR < than 100 mL
   • CATHETER USE
     • urinary catheters
       • mainstay management strategy
         • patients with NGB
       • clean intermittent catheterization
         • preferred method to
           • drainage in patients with NGB
         • increased risk of
           • UTI
             • caused by
               • catheter contamination
               • introduction of
                 • external microorganisms
     • are usually made of
       • silicone
       • other soft rubbers
         • to avoid trauma
   • IMMUNE DYSFUNTION
     • decreased
       • proinflammatory and inflammatory responses
         • to
           • uropathogenic Escherichia Coli
             • inflammation was not
               • suppressed after
                 • infection
     • may redisponse
       • to infection
       • hinder bacterial eradication
     • urine and urinary tract luminal space
       • contains
         • Escherichia Coli
         • Klebsiella Pneumoniae
           • invade urothelial cells
             • can proliferate within urothelium
               • not be easily eradicate with
                 • antibiotics treatment
                   • nidus of reinfection
     • pharmacology immunosuppression
       • further risk of recurrent UTI

4. DIAGNOSIS

   • a key factor complicating study and treatment
     • in UTI and NGB is
       • lack of consensus definition of infection
         • in study population
         • in clinical practice
   • impaired sensations
     • with non-specific symptoms
     • bacterial colonization in
       • bladder in patients with NGB
         • unclear clinical picture

5. MONITORING FOR INFECTION

   • universal agreement in NGB
     • renal
       • should be monitored
     • bladder

6. DEFINITIONS

   • UTI in pediatrics with spina bifida
     • equal or > 2 symptoms
       • fever > 38 C
       • abdominal pain
       • new back pain
       • new or worse incontinente
       • pain with catherization or urination
       • cloudy urine
     • > 100,000 colony forming units
       • single organism
     • > 10 white blood cells
   • UTI in patients with Spinal Cord Injury
     • > than 1000
       • intermittent catheterized specimen
     • > 100.000 CFU/mL from condon catheter
     • any value of
       • inderweiling suprapubic catheters
       • along with
         • piuria
         • signs and symptoms
           • of UTI

7. SYMPTOMS

   • typical symptoms
     • general population
       • disuria
       • urgency
       • frecuency
       • rarely present in
         • NGB population
   • symptoms in Spinal Cord Injury
     • autonomic disrreflexia
     • increased spasticity
     • urinary incontinence
     • vague back / abdominal pain
     • foul smelling urine

8. TREATMENT

   • urine cultures
     • must be obtained
       • before antibiotics
   • antibiotics choice
     • should be tailored
       • specific pathogen
         • sensitive trends in NGB population
           • differ from general population
   • recurrent courses of
     • antibiotics
       • results in
         • higher rates of
           • antibiotic-resistance
         • antibiotic prophylaxis
           • limited efficacy
             • related to
               • antibiotic resistance
   • duration
     • based on provider evxperience
       • few data supporting atb duration

9. ETIOLOGY

   • E. Coli
     • primary cause
       • in 18% of symptomatic patients
         • compared with 75 - 90% popular population