Urinary tract infections in spinal cord injury: prevention and treatment guidelines.

OBJECTIVES AND METHODS: The literature on prevention and therapy of urinary tract infection (UTI) in patients with spinal cord injury (SCI) was reviewed using 3 levels of evidence. RESULTS: Antibiotic therapy is only indicated in symptomatic bacteriuria or in symptomatic exacerbations of chronic UTI. During the acute phase of a SCI, UTI's are more prevalent and bacteria are different and more resistant to antibiotics compared with the chronic phase of SCI. In SCI in general, routine screening urine cultures are not valuable as a high species turn over is seen. Intermittent catheterisation, tapping or Crédé manoeuvre coincide significantly with lower frequency of UTI compared to permanent catheter drainage. No measures are proven efficient in the long term in prevention of bacteriuria or UTI. Methenamine salts are perhaps useful in the prevention of UTI but not in patients with a permanent catheter (level III). Antibiotic prophylaxis was found useful in reducing asymptomatic bacteriuria but not in the prevention of symptomatic infections (level I). However, during prophylaxis a doubling of antibiotic resistance was found. In patients with augmented bladder antibiotic prophylaxis is useless (level II). In chronic SCI the first choice antibiotics are nitrofurantoin or trimethoprim, the second choice are fluoroquinolones (level III) whereas in acute SCI a higher resistance profile to antibiotics is frequent and therefore fluoroquinolones or cefuroxime are suggested (level III). There is no consensus in the literature but we suggest 5 days of antibiotic treatment in UTI during chronic SCI without fever, 7 days in acute SCI without fever and a minimum of 14 days in patients with UTI and fever (level III).

A prospective randomized trial comparing the 1-stage with the 2-stage implantation of a pulse generator in patients with pelvic floor dysfunction selected for sacral nerve stimulation.

OBJECTIVE: The aim of this study was to evaluate in a prospective, randomized setting if the 2-stage implant, compared to a 1-stage implant, leads to a superior subjective or objective outcome of sacral nerve stimulation after implantation of the pulse generator in patients with lower urinary tract symptoms. PATIENTS AND METHODS: We implanted a sacral (S3) foramen lead and a pulse generator (model 3023, Medtronic Inc, Minneapolis, MN, USA) in 42 patients. They were randomized in a 1-stage or a 2-stage implant if a more than 50% improvement in voided volume or reduction of residual urine was seen during the test stimulation phase as compared to baseline. RESULTS: At 24 months follow-up, subjective (visual analogue scale) and objective (voided volume or residual urine) assessment were significantly better in the 2-stage group. Ten patients (24%) failed therapy, 7 in the 1-stage implant and 3 in the 2-stage group. Two patients were lost to follow-up. Logistic regression analysis revealed that failure was positively related to the 1-stage implant and negatively to the age of the patients. 76% of the treated patients had sustained clinical benefit with 23 revisions performed. The mean cost is respectively for the PNE (2006 Euro), for the 2-stage implant (10826 Euro) and for the 1 stage implant (8505 Euro). CONCLUSION: With this study, we demonstrated that the 2-stage implantation technique of the sacral neuromodulation therapy performed as a longer test stimulation phase has a higher success rate.

Elevated tubular proteinuria, albuminuria and decreased urinary N-acetyl-beta-D-glucosaminidase activity following unilateral total ureteral obstruction in rats.

UNLABELLED: Urinary tubular proteinuria and N-acetyl-beta-D-glucosaminidase (NAG) activity has not yet been studied after unilateral total ureteral obstruction (UTO). The aim of the study was (1) to evaluate in a longitudinal study (7 weeks) the behaviour and the potential clinical value of tubular proteinuria and urinary NAG activity after UTO; (2) to study the physiopathology of the non-obstructed contralateral kidney by using these two different markers of tubular damage. METHODS: in 28 female, adult Wistar rats (UTO: n = 16, sham: n = 12), tubular proteinuria and urinary NAG activity were measured before and 1 and 5 weeks after surgery. RESULTS: a significant (P < 0.01) increase in tubular proteinuria/creatinine ratio and urinary creatinine and a decrease in urinary NAG activity was found 1 week after UTO. All parameters normalized after 6 weeks. Albuminuria increased progressively (P < 0.01) during the study. CONCLUSION: tubular proteinuria increases during the first week following UTO in rats. The initial increase of low molecular weight proteins following UTO is not due to tubular damage as no parallel increase of urinary NAG was found. We suggest an initial tubular overperfusion with primary urine, due to an increased single nephron glomerular filtration and overruling the reabsorption capacity of the proximal tubules.