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Limited Vs Full Microbiological Investigation for the Management of Symptomatic Polymicrobial Urinary Tract Infection in Adult Spinal Cord- Injured Patients

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Limited Vs Full Microbiological Investigation for the Management of Symptomatic Polymicrobial Urinary Tract Infection in Adult Spinal Cord- Injured Patients Spinal Cord (1997) 35, 534 ± 539 1997 International Medical Society of Paraplegia All rights reserved 1362 ± 4393/97 $12.00 Limited vs full microbiological investigation for the management of symptomatic polymicrobial urinary tract infection in adult spinal cord- injured patients Rabih O Darouiche, Michael Priebe and Jill E Clarridge Baylor College of Medicine and the Veterans Aairs Medical Center, 2002 Holcombe Boulevard, Houston, Texas 77030, USA Spinal cord-injured (SCI) patients often suer from symptomatic polymicrobial urinary tract infection (UTI). The objective of this study was to evaluate the clinical outcome and cost- savings associated with antibiotic therapy based on limited vs full microbiological investigation of urine cultures in adult SCI patients with symptomatic polymicrobial UTI (52 organisms growing in urine cultures). In the ®rst part of the study, a total of 40 evaluable patients were prospectively randomized in a single-blinded fashion to receive antibiotic therapy based on either limited (21 patients) or full microbiologic investigation (19 patients) of urine cultures. The practicality of a limited microbiological investigation was further examined in the second part of the study where 12 consecutive patients with symptomatic polymicrobial UTI initially had only limited microbiological investigation of urine cultures and received antibiotic therapy accordingly. When analyzing all patients in the study, the likelihood of adequate clinical response was not signi®cantly dierent between those who received antibiotic therapy based on limited (28/33=85%) vs full (18/19=95%) microbiological investigation of urine cultures (P=0.40). An average of 183 US dollars could be saved per patient by managing symptomatic polymicrobial UTI based on a limited vs a full microbiological investigation. These results suggest that in adult SCI patients with symptomatic polymicrobial UTI antibiotic therapy guided by a limited microbiological investigation may be practical, adequate and cost-saving. Keywords: microbiological investigation; polymicrobial urinary tract infection; spinal cord injury Introduction Patients with spinal cord injury (SCI) commonly suer greater portion of SCI patients with clinical UTI are from a neuropathic bladder and become dependent on thought to have polymicrobial urine cultures. For bladder catheterization. By bypassing the urethra, the instance, almost half of positive urine cultures from most eective defense mechanism against infection, SCI patients with clinical UTI in our institution were placement of a catheter into the bladder has a high risk observed to grow 52 organisms in urine cultures; this of introducing bacteria into the urinary tract.1 ®nding is usually referred to as polymicrobial Although the risk of developing bacteriuria may be symptomatic UTI, although not all cultured organ- lower in SCI patients who undergo intermittent isms may contribute to signs and symptoms of UTI. catheterization of the bladder than those with There is no established way to accurately identify indwelling bladder catheters, urinary tract infection which cultured organism(s) is/are responsible for the (UTI) represents the most common infection in both particular clinical episode of polymicrobial UTI,7 groups of patients.2 It is not surprising, therefore, that thereby impairing the ability to administer antibiotic urine specimens constitute the largest number of therapy directed against only the pathogenic organ- specimens collected from SCI patients and processed ism(s). As a result, physicians generally request that at most clinical microbiology laboratories.3 clinical microbiology laboratories identify and perform It is generally reported that about 11 ± 31% of antibiotic susceptibility on most, if not all, organisms hospitalized patients with symptomatic UTI have isolated from urine cultures in patients with poly- polymicrobial growth in urine cultures.4±7 An even microbial UTI. This management approach is expensive and labor-intensive and usually leads to the administration of a broad-spectrum antibiotic Correspondence: RO Darouiche Presented in part at the 55th Annual Assembly of the American regimen that can possibly be associated with an academy of Physical Medicine and Rehabilitation, Miami, Florida, increased risk of developing adverse drug eects and U.S.A., 1993. bacterial resistance. Polymicrobial urinary tract infection RO Darouiche et al 535 Another potential approach in patients with therefore, helped narrow down the selection of symptomatic polymicrobial UTI entails administra- empirical antibiotics based on the recognized hospi- tion of antibiotic therapy guided by limited investiga- tal-based patterns of antibiotic susceptibilities for tion of urine cultures and monitoring the clinical various groups of organisms. Patients randomized to response of patients. Institution of processing controls group B received susceptibility-guided antibiotic for investigation of polymicrobial urine cultures at a therapy based on the information provided by clinical microbiology laboratory has been reported to complete microbiological investigation of urine cul- reduce the laboratory costs.3,8 However, the clinical tures. Identi®cation of bacteria and antibiotic suscept- impact on patient care and the overall savings ibilities were accomplished by standard bacteriologic attributed to guiding antibiotic therapy for sympto- methods.9 Although a complete microbiological in- matic polymicrobial UTI by only a limited micro- vestigation was performed on urine cultures from all biological investigation of urine cultures have not been patients enrolled in both groups A and B, the results of previously examined, particularly in the population of the complete microbiologic investigation were generally SCI patients in whom symptomatic UTI is often not made available to the physicians who treated polymicrobial. patients belonging to group A. Only in instances where The two main objectives of this study were to: (1) patients belonging to group A had not responded to compare the outcome of symptomatic polymicrobial their assigned empirical antibiotic therapy were the UTI in adult SCI patients who receive antibiotic results of a complete microbiological investigation therapy guided by a limited vs a full microbiological made known to the respective physicians. Patients investigation of urine cultures; and (2) determine the belonging to group A or B were managed by the same cost-savings that result from the use of the former vs group of primary care physicians. the latter approach for managing symptomatic Patients who were clinically judged to be too sick to polymicrobial UTI in this population. await the results of the limited or full microbiological investigation of urine cultures were started by the primary care physicians on initial pre-investigation Materials and methods antibiotic therapy sometime after obtaining the urine cultures. When the results of the microbiological Patient population investigation became available, patients were mana- Male patients who suered from symptomatic poly- ged according to one of three scenarios: (1) freshly microbial UTI while hospitalized at the 40-bed SCI started on the assigned form of antibiotic therapy; (2) Unit at the Veterans Aairs Medical Center, Houston, kept on the same pre-investigation antibiotic regimen Texas, USA, were eligible for enrollment in this study. that had been initially started (in this case, the day of An informed consent was obtained for all enrolled starting the assigned therapy is considered as that day patients. Symptomatic polymicrobial UTI was de®ned when initial pre-investigation therapy was started by the presence of polymicrobial bacteriuria (52 before receiving the results of the microbiological bacterial species growing from urine cultures, each at investigation of urine cultures); or (3) switched from a concentration of 5103 cfu/ml) and pyuria the initial pre-investigation antibiotic regimen to the (55 WBC/HPF), in association with one or more of assigned form of therapy (if the initial pre-investiga- the following clinical manifestations, including fever, tion antibiotic regimen was judged to lack coverage ¯ank or suprapubic tenderness, bladder spasm, dysuria, against 51 of the originally isolated organisms). change in voiding habits, nausea or vomiting, increase Patients with the clinical diagnosis of lower UTI in spasticity, worsening of dysre¯exia, and leukocyto- received a one-week course of assigned antibiotics sois; other potential etiologies for these clinical (usually per mouth, except if the results of antibiotic manifestations had to be excluded before symptomatic susceptibility testing indicated the need for parenteral UTI could be diagnosed. agents). Subjects with the clinical diagnosis of pyelonephritis (re¯ected by the presence of ¯ank pain or tenderness, nausea, vomiting, signs of clinical Study design: ®rst part sepsis, or associated bacteremia) were treated with This study consisted of two parts. The ®rst part was a antibiotics for 2 weeks (usually with parenteral agents prospective, randomized, single-blinded study. Patients during the ®rst week and with oral agents thereafter). enrolled into the ®rst part of the study were Patients were monitored at 3 ± 4 days after initiation of randomized into one of two groups (group A or B). antibiotic therapy and within a day of completing the Patients in group A received empirical antibiotic assigned antibiotic therapy. Monitoring consisted of therapy guided by the information provided
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