URINARY TRACT INFECTION AND NEUROGENIC BLADDER (NGB)

INTRODUCTION
1. micturition
  1. requires function of
    1. bladder
    2. urethral sphincter complex
    3. this process
      1. 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
EPIDEMIOLOGY
1. estimates NGB in USA
  1. approximately
    1. 400,000 people
      1. 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
2. increased
  1. frequency and severity of
    1. higher risk of
      1. morbidity
      2. mortality
      3. secondary to
        urosepsis
        end-stage renal disease
PATHOGENESIS
1. bladder dysfunction
  1. abnormal urodynamic parameters
    1. in patients with NGB
      1. increased rick of UTI
  2. detrusor overactivity
    1. decreased
      1. bladder compliance
  3. vesicoureteral reflux
    1. febrile UTI
      1. spinal dysraphism
  4. increased intravesical pressure
    1. bladder ischemia
      1. delayed or deficient
        inmune response to pathogen
    2. in
      1. distendent
      2. empty
        bladder
        suggest dysfunction
2. URINARY STASIS / INCREASED POSTVOID RESIDUAL
  1. normal voiding
    1. protects against UTI
      1. 99.9% of bacteria are removed by voiding
  2. inefficient voiding
    1. with residual urine
      1. development of UTI
  3. association between
    1. PVR urine / UTI
      1. among patients with spinal cord injury and NGB
        PVR > 300 mL
        4 to 5 times more UTI
  4. 2 studies of patients
    1. after stroke
      1. PVR after 150 mL
        risk factor
        UTI
      2. PVR after 100 mL
        4.9 - fold increased
        UTI
        from those with
        PVR < than 100 mL
3. CATHETER USE
  1. urinary catheters
    1. mainstay management strategy
      1. patients with NGB
    2. clean intermittent catheterization
      1. preferred method to
        drainage in patients with NGB
      2. increased risk of
        UTI
        caused by
        catheter contamination
        introduction of
        external microorganisms
  2. are usually made of
    1. silicone
    2. other soft rubbers
      1. to avoid trauma
4. IMMUNE DYSFUNTION
  1. decreased
    1. proinflammatory and inflammatory responses
      1. to
        uropathogenic Escherichia Coli
        inflammation was not
        suppressed after
        infection
  2. may redisponse
    1. to infection
    2. hinder bacterial eradication
  3. urine and urinary tract luminal space
    1. contains
      1. Escherichia Coli
      2. Klebsiella Pneumoniae
        invade urothelial cells
        can proliferate within urothelium
        not be easily eradicate with
        antibiotics treatment
        nidus of reinfection
  4. pharmacology immunosuppression
    1. further risk of recurrent UTI
DIAGNOSIS
1. a key factor complicating study and treatment
  1. in UTI and NGB is
    1. lack of consensus definition of infection
      1. in study population
      2. in clinical practice
2. impaired sensations
  1. with non-specific symptoms
  2. bacterial colonization in
    1. bladder in patients with NGB
      1. unclear clinical picture
MONITORING FOR INFECTION
1. universal agreement in NGB
  1. renal
    1. should be monitored
  2. bladder
DEFINITIONS
1. UTI in pediatrics with spina bifida
  1. equal or > 2 symptoms
    1. fever > 38 C
    2. abdominal pain
    3. new back pain
    4. new or worse incontinente
    5. pain with catherization or urination
    6. cloudy urine
  2. > 100,000 colony forming units
    1. single organism
  3. > 10 white blood cells
2. UTI in patients with Spinal Cord Injury
  1. > than 1000
    1. intermittent catheterized specimen
  2. > 100.000 CFU/mL from condon catheter
  3. any value of
    1. inderweiling suprapubic catheters
    2. along with
      1. piuria
      2. signs and symptoms
        of UTI
SYMPTOMS
1. typical symptoms
  1. general population
    1. disuria
    2. urgency
    3. frecuency
    4. rarely present in
      1. NGB population
2. symptoms in Spinal Cord Injury
  1. autonomic disrreflexia
  2. increased spasticity
  3. urinary incontinence
  4. vague back / abdominal pain
  5. foul smelling urine
TREATMENT
1. urine cultures
  1. must be obtained
    1. before antibiotics
2. antibiotics choice
  1. should be tailored
    1. specific pathogen
      1. sensitive trends in NGB population
        differ from general population
3. recurrent courses of
  1. antibiotics
    1. results in
      1. higher rates of
        antibiotic-resistance
      2. antibiotic prophylaxis
        limited efficacy
        related to
        antibiotic resistance
4. duration
  1. based on provider evxperience
    1. few data supporting atb duration
ETIOLOGY
1. E. Coli
  1. primary cause
    1. in 18% of symptomatic patients
      1. compared with 75 - 90% popular population

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URINARY TRACT INFECTION AND NEUROGENIC BLADDER (NGB)

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