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ORIGINAL ARTICLE
Validity of urine dipstick test to assess eradication of urinary tract infection in persons with spinal cord injury
Validité de la bandelette urinaire dans l’évaluation de l’éradication des infections urinaires chez les patients blessés médullaires
J.G. Previnaire
a,∗, J.M. Soler
b, L. Chouaki
a, L. Pawlicki
c, M. Le Berre
a, E. Hode
a,d, P. Denys
eaCentreCalvé,fondationHopale,72,esplanadeParmentier,62600Berck-sur-Mer,France
bLaboratoired’urodynamiqueetdesexologie,centreBouffard-Vercelli,Cap-Peyrefite, 66290Cerbère,France
cLaboratoiredebiologiemédicale,fondationHopale,62600Berck-sur-Mer,France
dUrologie,centreCalot,fondationHopale,62600Berck-sur-Mer,France
eHôpitalRaymond-Poincaré,Assistancepublique—HôpitauxdeParis(AP—HP), 92380Garches,France
Received9December2016;accepted30March2017 Availableonline4May2017
KEYWORDS Urinarytract infection;
Spinalcordinjury;
Urinedipstick;
Antibiotictherapy;
Predictivevalue;
Bacteriuria
Summary
Objectives.—Toprospectively studythe predictivevalue (PV)ofurine nitrite(NIT)dipstick testingagainsturineculturesduringantibiotictreatmentforurinarytractinfection(UTI),and othersituations,inpatientswithspinalcordinjury(SCI).
Methods.—InpatientswithSCIonintermittentcatheterisation(IC)oraFoleyindwellingcathe- ter(FC)wereincluded.Urinespecimenswerecollectedinpatientswithoutsymptoms(routine), withsymptomsofUTI(suspicion),andonday4ofa5-dayantibiotictreatment(ATB+3).
∗Correspondingauthor.
E-mail addresses: previnjg@hopale.com (J.-G. Previnaire), jmsoler66@aol.com(J.-M. Soler), lila.chouaki@gmail.com (L. Chouaki), lpawlicki@hopale.com(L.Pawlicki),leb.morgane@gmail.com(M.LeBerre),ehode@nordnet.fr(E.Hode),pierre.denys@rpc.ap-hop-paris.fr (P.Denys).
http://dx.doi.org/10.1016/j.purol.2017.03.009
1166-7087/©2017ElsevierMassonSAS.Allrightsreserved.
Results.—Atotalof157urinesampleswerecollectedin61patients:34wereonIC(95samples) and27onFC(62samples).Theprevalenceofasymptomaticbacteriuriaintheurinecultures was89%inroutine(70samples).AtATB+3,microbiologicalcurewasfoundin27/30specimens (ICgroup)and2/6(FCgroup).Intheroutinecondition,thespecificityandpositivePVofthe NITtestswas1.00andsensitivity0.63.ThenegativePVwaslowinbothgroups.Insuspicionof UTI,thesensitivitywasbetween0.69and0.55,thepositivePVwas1.00andthenegativePV 0.00forbothgroups.AtATB+3,thenegativePVandsensitivitywas1.00,specificity0.85and positivePV0.43intheICgroup,andintheFCgroup,specificitywas1.00,negativePV0.33and sensitivity0.00.
Conclusion.—IntheSCIpopulationonintermittentorindwelling catheterswithhighpreva- lenceofbacteriuria,dipsticktestinghelpedassesstheeradicationofgermsduringantibiotic treatment,butshowednovalueinthedecisionmakingprocessforUTI.
Levelofevidence.— 3.
©2017ElsevierMassonSAS.Allrightsreserved.
MOTSCLÉS Bandeletteurinaire; Infectionurinaire; Blessémédullaire; Antibiothérapie; Valeurprédictive; Bactériurie
Résumé
Objectif.—Étudeprospectivedelavaleurprédictive(VP)desbandelettesurinairescomparées àl’ECBU,dansdifférentesconditionscliniques,chezlepatientblessémédullaire(BM).
Méthode.—PatientsBMhospitaliséspratiquantlessondagesintermittents(SI)ouensondeà demeure(SAD).LesECBUontétéprélevéschezdespatientssanssymptômes(routine),avec symptômesd’infectionurinaire(suspicion)ouau4ejourd’untraitementantibiotique(ATB+3).
Résultats.—Untotalde157ECBUontétécollectéschez61 patients:34auxSI(95échan- tillons)et27enSAD(62échantillons).Laprévalencedelabactériurieasymptomatiquechez despatients asymptomatique(routine)étaitde89%(70ECBU).À ATB+3, l’éradicationdes germes(ECBUstérile)étaitretrouvéesur27/30échantillonsdanslegroupeSIet2/6dansle groupeSAD.Enroutine,la spécificitéetla VPpositive desbandelettes urinairesétaientde 1,00etlasensibilitéde0,63.LaVPnégativeétaitfaibledansles2groupes.Encasdesuspicion d’infection,lasensibilitéétaitentre0,69et0,55,laVPpositivede1,00etlaVPnégativede 0,00pourles2groupes.ÀATB+3,laVPnégativeetlasensibilitéétaientde1,00,laspécificité de0,85etlaVPpositivede0,43danslegroupeSI,laspécificitéde1,00,laVPnégativede 0,33etlasensibilitéde0,00danslegroupeSAD.
Conclusion.—LaVPnégativedesbandelettesurinairesestparticulièrementintéressantepour diagnostiquerl’éradicationdesgermes.Lesbandelettesurinairesn’ontaucunintérêtdansle diagnosticd’infectionurinairechezlespatients médullairesauxSIouenSAD,dufait dela prévalenceélevéedelabactériurie.
Niveaudepreuve.— 3.
©2017ElsevierMassonSAS.Tousdroitsr´eserv´es.
Introduction
Bacteriuria, either symptomatic or not, is the most com- monmedicalcomplicationinpatientswithspinalcordinjury (SCI), both in the acute phaseand throughout their life- time[1—3].Prevalenceoflowerurinarytractcolonization (asymptomaticbacteriuria)hasbeenreportedbetween50%
and 90%, both at home and in hospital [4—6], while uri- nary tract infection (UTI — symptomatic bacteriuria) and urinarycomplicationsarethefirstcauseofrehospitalisation intetraplegicpatients[7].
ThediagnosisofsymptomaticUTIisbasedonacombina- tionofclinicalsignsandbacteriologicalcriteriadetermined fromurinecultures[8—10].Symptomsincludeurinary,blad- deror generalsigns[9,11],while significant bacteriuriais
dependentonthemode ofvoiding. However,culturesare costly,timeconsumingand requireat least 24hours[12].
Over the last thirty years, the urinary dipstick test has becomeincreasingly usedasan alternative, asit ischeap andcanbeusedasabedsidetest,enablingaquickdiagno- sis.Studieshaveshownitsutilityinvarietynon-neurological disorders,particularlytoruleoutinfections[12].
InpatientswithSCI,dipstickresultsfornitrite(NIT)and leukocyteesterase (LE) are part of the essential compo- nentsof theUTI basic dataset [11],and arewidely used inrehabilitationsettings[13].However,thereisaclearlack ofscientific evidence tosupporttheir utility and thereis stillsome confusion as to the validity of dipstick testing toconfirminfection. Ina recentreview of theliterature, Cameronetal.concludedthatNITandLEdipsticksaresen-
sitiveandspecificforpredictingaUTI[4].The resultsare particularlyrobustwhenapositiveNITorLEisconsidered [6,14].Therateofmissedinfectionsandundertreatmentis low,makingitanexcellentscreeningtest[4].However,the earlierstudybyHoffmanetal.foundpoorsensitivity(64%) andspecificity (52%), suggesting that reliance ondipstick testingalonecouldleadtoahighrateofovertreatmentfor UTI[6].
NewregulationsinFrancestatethattheeffectivenessof antibioticregimens, whetherprescribed following culture resultsorclinicalsigns,shouldbeassessedinthefirstdays ofthetreatment,inordertocontrolantimicrobialoveruse andresistance[15].
Theaimofthisprospectivestudywastoassessthecli- nical value of dipstick testing as an alternative to urine culture,toassesstheeffectivenessofantibiotictreatment, aswellasitsutilityduringroutinetestingandsuspicionof UTI,inpersonswithSCIonICorwithanindwellingcatheter.
Material and methods Patients
FromJanuarytoSeptember2013,urinalysis,urineculture andautomateddipstickanalysis(ClinitekTM)wereprospecti- velyperformedonallurinesamplestakenfromallinpatients withSCI. Patientswere included ifthey wereon only IC, ICcombinedwithspontaneousvoiding,orindwellingcathe- ters.Patientswitharecenthistoryofantibiotictreatment (within2weeks)orpresentingwithasuspicionoffebrileUTI (temperatureabove38◦5C)wereexcluded.
Theurinespecimensweredividedintothreeconditions foranalysis:
• routine:onadmission,priortohydrotherapyorurodyna- mictests;
• suspicion of a non-febrile UTI (temperature less than 38◦5C);
• on day 4 (ATB+3) of a 5-day course of antibiotics for significantbacteriuriawithorwithoutsymptoms.
Early morning urine samples were collected whenever possible.Urineforculturewasalwayscollectedasaclean- catchmidstreamtechniquefor patientsonIC,andfroma newurinecatheter wheneverpossiblefor those withind- wellingcatheters.
Atthetimethesamplewascollected,participantscom- pletedaspecificallydesignedquestionnairewiththenurse, inwhichtheyreportedanyclinicalsignsorsymptoms.This includedurinarysignssuchascloudy ormalodorousurine, bladdersignssuchasurinaryincontinence,urgencyormodi- ficationofbladderbehavior(decreased bladdercapacity), andgeneralsignssuchasfeverwithoutothercauses,increa- sedspasticity,boutsofautonomicdysreflexiaandsenseof unease(suprapubicpain).
Urinesampleswerecollectedusingstandardprocedures (clean or aseptic IC, when performed by the patients or thenurses,respectively)orasepticallythroughthecathe- ter port and were immediately sent to the microbiology laboratory.Severalsamplescouldbeincludedforthesame patient.
Ethicalapprovalwasnotrequiredforthisstudysinceit involvedroutinetreatmentwithnobloodsamples.
Laboratory methods
Thesampleswereprocessedwithin3hoursofcollection.
Dipstickanalyseswereperformedfirst,withtheremain- derofthesampleusedforurinecultureandurinalysis.
ClinitekTMwasusedfordipstickchemicalurineanalysis.
Colony-formingunits(cfu)werecountedbythesurface streak methodusingCPSagar(BioMérieux, Marcyl’Étoile, France).Theminimaldetectionlimitwas20cfu/mL.Other culture plates were usedas appropriateaccording to the resultsofGramstainsmearexamination.Bacterialspecies wereidentifiedaccordingtostandardmethods.
Definitions
DipsticktestsweredefinedaspositiveifeitherNITorLEwas positive.
Forurinecultures,thecriteriaoftheAmericanParaple- giaSocietywerefollowed:
• significant bacteriuria: a threshold of 102cfu/mL for patientsonICandanydetectableconcentrationforspe- cimensfromindwellingcatheters;
• UTI:significantbacteriuriaandatleastoneclinicalsign orsymptom;
• asymptomaticbacteriuria:significantbacteriuriawithout anyclinicalsigns.
Toevaluatetheeffectivenessoftheantibiotictreatment, thefollowingdefinitionswereused:
• microbiologicalcure:urinecultureswithnegativeresults atATB+3;
• clinicalcure:theabsenceofurinarysymptoms.
Clinicalsigns were considered positive if there wasat least one sign or symptom withinone of the 3 subgroups (urinary,bladderorgeneralsigns).
Thepatientswerecategorizedintotwogroups,according totheirmethodofbladderdrainage(ICandFoleyindwelling catheter[FC]).
Statistical analysis
The resultsof theurine cultureswerecomparedwiththe dipstickresultsforNITandLEineachgroupofpatients(IC andFC).
Validityofthescreeningtest:sensitivity,specificityand predictivevalues(PV)werecalculatedforpositiveNITtests, positive LE tests, both positive and negative NIT and LE tests,andeitherpositiveNITorLEtestscomparedwithurine cultureresultsineachclinicalcondition(routine,suspicion ofUTIandATB+3).
Results
Atotalof157urinesamplesfrom61patientswereincluded.
Twenty patients had paraplegia, 41 tetraplegia, 14 were femaleand47weremale.Theircharacteristicsareshown inTable1.Thirty-fourpatientswereonIC(95samples)and 27onFC(62samples).Seventysampleswereroutine,51for
Table1 Patientcharacteristics.
Intermittent catheter
Foley catheter Tetraplegic
Paraplegic
14 20
27
—
Female/male 7/27 7/20
AISA/B/C/D 22/5/3/4 20/5/0/2
Timesincelesiononset (years)
6.0±9.3 (0.1—42.3)
3.4±5.8 (0.1—24.3) CIC/reflexvoiding+CIC
Indwelling/suprapubic catheter
31/3
—
− 26/1
Urinesamples(n) 95 62
AIS:ASIAInjuryScale;CIC:cleanintermittentcatheterization.
suspicionofUTI,and36onday4ofantibiotictreatmentfor UTI(ATB+3).Oneto12sampleswerecollectedperpatient.
Urine culture
Intheroutinecondition(patientswithoutsymptoms),signi- ficantbacteriuriawasfoundin35outof36samplesinthe IC group,and 29 out of 34 samples in theFC group. The prevalence of asymptomatic bacteriuria was 89% for the 56patients.TheprevalencewashigherintheICgroup(97%) thanintheFCgroup(81%).InthesuspicionofUTIcondition, allsampleshadsignificantbacteriuria.
Significantbacteriuriawastreatedwithantibioticsin36 cases:22 following suspicionof UTI and 14 beforeurody- namictestingorhydrotherapy.Antibiotictherapyfollowed antimicrobialsusceptibilitytestingin27casesandwasempi- ricallystartedin9.
Antibiotics were prescribed as single treatments in 33 cases (cefixime [12], Nor- or ciprofoxacine [1], trime- thoprim/sulfamethoxazole [7], nitrofurantoin [3] and as dualtherapiesin3cases:amikacin+cefixime[1],gentamy- cin+ciprofloxacin[1]orfosfomycintrometamol[1]).
At ATB+3,microbiologicalcurewasfound in 27outof 30specimensintheICgroupand2outof6specimensinthe FCgroup.
Treatment failurewasmainlydue toreinfection witha changeinthebacterialstrain(6specimens:2intheICgroup [7%]and4intheFCgroup[67%]),whilethesamebacteria
persistedinonespecimen(onepatientonIC).Thecausative bacteriawerethuseradicatedin35outof36specimens.
Leukocyturia≥103wasfoundinall157specimens,inclu- dingthe29specimens,whichhadmicrobiologicalcure.
Clinical signs
SuspicionofUTI(51samples)wasbasedonone,oracombi- nationofurinarysignsfor36cases,bladdersignsfor17cases andgeneralsignsfor22cases.
At ATB+3, clinical cure occurred in 20 out of the 22patientswithsuspicionofUTIandbladdersignspersisted in2patientsonICdespitemicrobiologicalcure.
Dipsticks
The results and comparisons of dipstickand culture tests arepresented in Tables 2—5. As can be seen in Table 3, the predictive value of the dipstick-screening test varied greatlydependingonwhetherNITwasconsideredaloneor incombinationwithLE.
It must benoted that in thisstudy, apositive dipstick LE could not be used as a discriminant factor since the urinalyses showed leukocyturia in all samples. Thus, the discussionof dipstickfindings is basedontheNIT results.
Furthermore,care must betaken inthe interpretation of someresultsduetothesmallnumberofnegativedipsticks intheroutineandsuspicionofUTIconditions.
Dipstick testing for NIT compared with significant bacteriuria
Intheroutinecondition (absenceof symptoms),NITtests hadexcellentspecificityandpositivePVof1.00,withsen- sitivityof0.63and0.66,butlownegativePV.Thefirsttwo resultscanbeattributedtotheabsenceoffalsepositivesin bothgroups(positiveNITwithasymptomaticbacteriuria).
InthesuspicionofUTIcondition(presenceofsymptoms), thesensitivityoftestsforNITwashigherintheICthanin theFCgroup(0.69vs.0.55).ThepositivePVwas1.00and negativePV 0.00, for both groups. The latter tworesults canbeattributedtotheabsenceofnegativeurinecultures inbothgroups.
AtATB+3,theresultsofthetestsforNITdifferedsignif- icantlybetweenthe2groups.IntheICsamples,therewas anegativePVandsensitivityof1.00,specificityof0.85but
Table2 Resultsofurineculturesanddipsticktestingineachcondition.
Intermittentcatheter Foleycatheter
Urineculture DipstickNIT Urineculture DipstickNIT
+ — + — + — + —
Routine 35 1 22 14 29 5 19 15
SuspicionUTI 29 0 20 9 22 0 12 10
ATB+3 3 27 7 23 4 2 0 6
Total 67 28 49 46 55 7 31 31
NIT:nitrite;UTI:urinarytractinfection;ATB+3:fourthdayofantibiotictreatment.
Table3 Predictivevaluesofurinedipstickanalysisagainsturinecultureintheroutinecondition.
Sensitivity Specificity PositivePV NegativePV
NIT IC 0.63(0.79—0.47) 1.00(1.00—1.00) 1.00(1.00—1.00) 0.07(from0.21to
−0.06)
FC 0.66(0.83—0.48) 1.00(1.00—1.00) 1.00(1.00—1.00) 0.33(0.57—0.09) LE IC 0.43(0.59—0.26) 0.00(0.00—0.00) 0.94(1.06—0.82) 0.00(0.00—0.00) FC 0.76(0.91—0.60) 0.80(1.15—0.45) 0.96(1.04—0.87) 0.36(0.65—0.08) NITorLEpositive IC 0.80(0.93—0.67) 0.00(0.00—0.00) 0.97(1.03—0.90) 0.00(0.00—0.00) FC 0.90(1.01—0.79) 0.80(1.15—0.45) 0.96(1.03—0.89) 0.57(0.94—0.20) NITandLEpositive IC 0.26(0.40—0.11) 1.00(1.00—1.00) 1.00(1.00—1.00) 0.11(from0.11to
−0.03)
FC 0.52(0.70—0.34) 1.00(1.00—1.00) 1.00(1.00—1.00) 0.26(0.46—0.07) NITandLEnegative IC 0.20(from0.33to
−0.07) 1.00(1.00—1.00) 1.00(1.00—1.00) 0.03(from0.10to
−0.03) FC 0.10(from0.21to
−0.01) 0.20(from0.55to
−0.15) 0.43(0.80—0.06) 0.04(from0.11to
−0.03) Valuesaregivenwithconfidenceintervalsinbrackets.IC:intermittentcatheterization;FC:Foleycatheter.
Table4 PredictivevaluesofurinedipstickanalysisagainsturinecultureinsuspicionofUTI.
Sensitivity Specificity PositivePV NegativePV
NIT IC 0.69(0.86—0.52) — 1.00(1.00—1.00) 0.00(0.00—0.00)
FC 0.55(0.75—0.34) — 1.00(1.00—1.00) 0.00(0.00—0.00)
Valuesaregivenwithconfidenceintervalsinbrackets.IC:intermittentcatheterization;FC:Foleycatheter.
Table5 PredictivevaluesofurinedipstickanalysisagainsturinecultureforATB+3.
Sensitivity Specificity PositivePV NegativePV
NIT IC 1.00(1.00—1.00) 0.85(0.99—0.72) 0.43(0.80—0.06) 1.00(1.00—1.00)
FC 0.00(0.00—0.00) 1.00(1.00—1.00) — 0.33(from0.71to−0.04)
ATB+3:fourthdayofantibiotictreatment.Valuesaregivenwithintervalconfidencesinbrackets.IC:intermittentcatheterization;FC:
Foleycatheter.
lowpositivePVof0.43.IntheFCsamples,therewasspeci- ficityof1.00withlownegativePVof0.33andsensitivityof 0.00.
Bacteria
Asinglebacteriumwasfoundin104specimensand2bacte- ria were found in 17 specimens. Twelve different strains ofbacteriawerefound (Table6),ofwhich themostcom- monwereEscherichiaColi(36%)andKlebsiellaPneumoniae (18%).PseudomonasAeruginosa wasmostlypresent inthe FCsamples(18%inthisgroup).
Discussion
TheresultsofthisstudyshowedthatdipsticktestingforNIT hadahighspecificityandexcellentnegativePVtoconfirm microbiological cure(in patients onIC only), and limited clinical value torule outsignificant bacteriuria (routine),
Table6 Strainsofbacteriafoundintheurinesamples.
Bacteria IC FC Total
EscherichiaColi 30 20 50
KlebsiellaPneumoniae 18 7 25
PseudomonasAeruginosa 1 12 13
EnterobacterAerogenes 9 2 11
EnterococcusFaecalis 3 7 10
StaphylococcusAureus 2 7 9
ProteusMirabilis 3 6 9
EnterobacterCloacae 3 1 4
CorynebacteriumSpp. 3 3
SerratiaMarcescens 1 1 2
StaphylococcusCoagulaseNegative 1 1
AcinetobacterBaumanii 1 1
Total 71 67 138
IC:intermittentcatheterization;FC:Foleycatheter.
or confirm UTI (presence of clinical signs). Urine culture atATB+3showederadicationofthecausativegermsinall butonepatient,whilereinfection(bacterialchange)mostly occurredintheFCgroup.Urinalaysisshowedpersistenceof leukocyturiainallpatients,eveninthecaseofmicrobiolo- gicalcure.
TheexcellentpositivePV(1.00)foundinthisstudyinthe routineandsuspicionofUTIconditionsis,atfirstsight,cli- nicallyrelevant. Areliablypositivedipstickwouldbevery useful to rule in symptomatic bacteriuria or UTI, order a urineculture andstart empiricantibiotictreatment when necessary.However,asymptomaticbacteriuriaiscommonin patientswithSCI, withreportedprevalencesbetween30%
and89%[4,5].In thestudybyHoffmanetal.,ondipstick testing in patients withSCI living at home,asymptomatic bacteriuriawasfoundin81%ofthesamples[6].Inthisstudy, wefoundsignificant bacteriuriain91%ofthesamplesand estimated the prevalence of asymptomatic bacteriuria at 89%.Thus,theclinicalvalueofthistestisclearlylimited.
Relianceondipstickresultscouldleadtohighratesofover- treatmentforUTI.Urineculturesarethereforemandatory toensureappropriatetreatment[6].
Inpatientswithnon-neurologicaldisorders,dipsticktes- tinghasbeenshowntobevalid,mainlytoruleoutinfections [12], but surprisingly, studies have rarely compared the negativePV of dipstick testing withcultures.Two studies reportedagoodnegativePV:from0.91to0.98(combined for LE, NIT and protein) [16], and 0.95 (combined for LE andNIT)[14],whileanotherstudylaterfoundalownega- tive PV of 0.35 for significant bacteriuria and a negative PVof 0.78for positiveUTI(combined forLE andNIT)[6].
Anotherstudy concludedthat asymptomatic patientswith SCIwhopresentforannualevaluationsshouldnotundergo routineurineculturesiftheyhavenegativenitrite[17].In our study, the negative PV of the dipstick test was very poorintheroutineandsuspicionofUTIconditions,butwas excellentforATB+3inpatients onIC.Moreover,itssensi- tivitywasexcellent(1.00).Thedipsticktestcantherefore besafelyusedtoruleoutsignificantbacteriuriaandconfirm theeffectivenessofantibiotictreatment.
Leukocytes
Thepresenceofleukocytesintheurine,whichreflectsthe inflammatory state of the bladder, might help distinguish betweentrueinfectionandcolonization[2].Inpatientswho donothaveSCI,pyuriaisanexcellentindicatorofinfection:
pyuriaisalmostalwayspresent(>96%)insymptomaticUTI, is often present (∼50%) inasymptomatic bacteriuria, and israre(<1%)inpatientswithasymptomaticnon-bacteriuria [1,18].
In patients with SCI, leukocyturia is a frequent fin- ding becausethe bladderwall is irritatedby intermittent catheterization or indwelling catheters, even when there is no infection [8]. We further showed that leukocyturia waspresent inallsamples,in theICand FCgroups alike, including those withmicrobiological cure at ATB+3. This highlightsthelowspecificityofLEasadiagnostictestforUTI [1]andthatNITshouldbepreferentiallyconsidered when carryingoutdipsticktesting.Quantitativecriteriaforasses-
singpyuriainpersonswithSCI haveyet tobedetermined forurinalysis[2].
Clinical signs
Signsandsymptomsareincluded intheUTIbasicdataset [11],howeverclinicalmanifestationsofUTIareoftenatypi- calandnonspecificinpatientswithSCIandmayinvolveonly aggravation of preexisting neurological symptoms, while someverysuggestive symptomssuchasfever mayhave a non-infectiousorigin[19].
Urinarysignsareusuallyconsideredtohavethehighest accuracyforthediagnosisofUTI[2,20].Thenumberofcli- nicalsignsisundoubtedlyamajordiagnosticfactor[2].In thecaseofmicrobiologicalcureatATB+3,weshowedthat urinarysignsandmostotherclinicalsignsalwaysdisappea- red,exceptforthebladdersignsthatpersistedin2cases, suggestingthatthesesignsarelessspecific.
Mid-treatment assessment of ATB effectiveness
Reassessmentof clinicaland microbiologicaleffectiveness of antibiotic regimens should be part of good clinical practice[15].Confirmationoferadicationofgermsatmid- treatmentis necessary toensureATBsarecorrectly used.
Therearelimiteddataonthemid-treatmenteffectofanti- bioticsinUTI.Inastudyofcatheter-freepatientswithSCI undergoing7—14 day coursesof antibiotics, Waites etal.
foundmid-treatmenturinesterilityratesof54%[21]while Stannard et al. found that 97% of patients had negative culturesonday3oftreatmentinastudyof38hospitalized patientswithSCItreatedwithciprofloxacinfor5days[22].
Inthepresentstudy,eradicationofthecausativegermwas achievedin35/36(97%)samplesandmicrobiologicalcurein 29/36(81%)samplesbyday4.Thisheterogeneityinratesof curemight be related todifferences in the effectiveness of the antibiotics used or variations in microbial charac- teristics andvirulence factors of the infecting organisms.
Treatment failurewasdue toreinfection (6/7),mainly in theFCgroup.Inpatientsonindwellingcatheterizationthe riskofUTIis4-timesgreaterthaninthoseonotherbladder drainagemethods(oddsratio4.04)[23].
TheoptimaldurationofATBtreatmentforUTI isstilla matterofdebate.Thepromptclinicalandmicrobiological responsetotreatmentobservedinthisstudy(day4)supports theprescriptionofshortcoursesofantibiotics(5to7days), whichpotentialbenefitscouldincludeareductioninadverse effects,antimicrobialresistanceandcost[24].
Conclusion
Thisstudyshowedthatinthespecificpopulationofpatients withSCIwithahighprevalenceofbacteriuria,dipsticktes- tinghasahigh positivePV butdoes nothelp thedecision makingprocessforUTIanddoesnotavoidurinecultures.
DipsticktestinghasanexcellentnegativePVandisthus usefultoconfirmapromptresponsetoantibiotictreatment, especiallyinpatientswithslightbacteriuria(patientsonIC andmostprobablythosewhoarecatheter-free).
Future research should assess the usefulness of sys- tematic mid-treatment urine tests (either with dipstick or culture) to help discriminate responders from non- responders to antibiotics and to determine optimal treatmentduration.
Acknowledgements
Weare gratefulto Dr VinckeBernard for statistical assis- tance,andtoJohannaRobertsonforrevisionoftheEnglish
Disclosure of interest
Theauthorsdeclarethattheyhavenocompetinginterest.
References
[1]CardenasDD, Hooton TM.Urinarytract infectionin persons withspinalcordinjury.ArchPhysMed1995;76(3):272—80.
[2]RoncoE,DenysP,Bernede-BauduinC,LaffontI,MartelP,Salo- mon J, et al. Diagnostic criteria of urinary tract infection inmalepatientswithspinalcordinjury.NeurorehabilNeural Repair2011;25(4):351—8.
[3]WyndaeleJJ.Intermittentcatheterization:whichistheopti- maltechnique?Spinalcord2002;40(9):432—7.
[4]Cameron AP,Rodriguez GM,SchomerKG. Systematicreview of urological followup after spinal cord injury. J Urol 2012;187(2):391—7.
[5]ColganR, NicolleLE,McGloneA, HootonTM.Asymptomatic bacteriuriainadults.AmFamPhysician2006;74(6):985—90.
[6]Hoffman JM, Wadhwani R, Kelly E, Dixit B, Cardenas DD.
Nitriteandleukocytedipsticktestingfor urinarytractinfec- tioninindividualswithspinalcordinjury. JSpinalCordMed 2004;27(2):128—32.
[7]KlotzR,JosephPA,RavaudJF,WiartL,BaratM,TetrafigapG.
TheTetrafigapSurveyonthelong-termoutcomeoftetraplegic spinalcordinjuredpersons:partIII.Medicalcomplicationsand associatedfactors.SpinalCord2002;40(9):457—67.
[8]Gribble MJ, Puterman ML, McCallum NM. Pyuria: its rela- tionship to bacteriuria in spinal cord injured patients on intermittent catheterization. Arch Phys Med Rehabil 1989;70(5):376—9.
[9]NIDRR. National Institute on Disability and rehabilitation research Consensus Statement(NIDRR). The prevention and
management of urinarytract infections among people with spinalcordinjuries.JAmParSoc1992;33(15):194—204.
[10]VigilHR,HicklingDR.Urinarytractinfectionintheneurogenic bladder.TranslAndrolUrol2016;5(1):72—87.
[11]GoetzLL,CardenasDD,KennellyM,BonneLeeBS,Linsenmeyer T,MoserC,etal.Internationalspinalcordinjuryurinarytract infectionbasicdataset.Spinalcord2013;51(9):700—4.
[12]DevilleWL,YzermansJC,vanDuijnNP,BezemerPD,vander WindtDA,BouterLM.Theurinedipsticktestusefultoruleout infections.Ameta-analysisoftheaccuracy.BMCUrol2004;4:4.
[13]PannekJ.Treatmentofurinarytractinfectioninpersonswith spinalcordinjury:guidelines,evidenceandclinicalpractice.
Aquestionnaire-basedsurveyandreviewoftheliterature.J SpinalCordMed2011;34(1):11—5.
[14]TuelSM,MeythalerJM,CrossLL,McLaughlinS.Cost-effective screening by nursing staff for urinary tract infection in the spinal cord injured patient. Am J Phys Med Rehabil 1990;69(3):128—31.
[15]HAS.Stratégied’antibiothérapieetpréventiondesrésistances bactériennesenétablissementdesanté;2008.
[16]GutmanSI,SolomonRR.Theclinicalsignificanceofdipstick- negative,culture-positiveurinesinaveteranspopulation.Am JClinPathol1987;88(2):204—9.
[17]JayawardenaV,MidhaM.Significanceofbacteriuriainneuro- genicbladder.JSpinalCordMed2004;27(2):102—5.
[18]StammWE.Measurementofpyuriaanditsrelationtobacte- riuria.AmJMed1983;75(1B):53—8.
[19]LinsenmeyerTA,OakleyA.Accuracyofindividualswithspinal cordinjuryatpredictingurinarytractinfectionsbasedontheir symptoms.JSpinalCordMed2003;26(4):352—7.
[20]MassaLM,HoffmanJM,CardenasDD. Validity,accuracyand predictivevalueofurinarytractinfectionsignsandsymptoms inindividualswithspinalcordinjuryonintermittentcathete- rization.JSpinalCordMed2009;32(5):568—73.
[21]Waites KB, Canupp KC, DeVivo MJ. Eradication of uri- nary tract infection following spinal cord injury. Paraplegia 1993;31(10):645—52.
[22]Stannard AJ, Sharples SJ, Norman PM,Tillotson GS. Cipro- floxacintherapyofurinarytractinfectionsinparaplegicand tetraplegicpatients:abacteriologicalassessment. JAntimi- crobChemother1990;26(Suppl.F):13—8.
[23]EsclarinDeRuzA,GarciaLeoniE,HerruzoCabreraR.Epide- miologyandriskfactorsforurinarytractinfectioninpatients withspinalcordinjury.JUrol2000;164(4):1285—9.
[24]DowG,RaoP,HardingG,BrunkaJ,KennedyJ,AlfaM,etal.A prospective,randomizedtrialof3or14daysofciprofloxacin treatmentfor acuteurinary tractinfection inpatientswith spinalcordinjury.ClinInfectDis2004;39(5):658—64.