Incidence of urinary tract infection following initiation of intermittent catheterization among patients with recent spinal cord injury in Germany and the Netherlands

Figures & data

Figure 1 Sample selection criteria. Abbreviations: AIS, American Spinal Injury Association Impairment Scale; IC, intermittent catheterization; SCI, spinal cord injury; UTI, urinary tract infection.

Table 1 Definitions of UTI.

Criterion	NIDRR definition	CMS definition	Togan definition	EAU definition	Burgdörfer definition	Any mention of UTI
Bacteriuria	10^2 CFUs	10,000 CFUs/mL	≥10^5 CFU/mL	>10^4 CFU/mL*	≥10^5 CFU/mL	–
Pyuria	WBC > 10 or positive leukocyte esterase	>5 leukocytes per high-power field	–	>10 WBCs	≥100 leukocytes/mm^3	–
Signs and Symptoms
Leukocytes/leukocytosis	Presence in urine, produced by the mucous membrane	Systemic leukocytosis		–	–	–
Discomfort or pain	Above kidneys or bladder or when urinating	–	Abdominal pain, pains on side, or in suprapubic region	–	–	–
Start of urinary incontinence or leakage around the catheter	Yes	–	–	–	–	–
Fever or shivers	Yes	Yes (Oral temperature >38°C (or 100.4°F))	Yes (>38°C)	–	–	–
Anorexia	Yes			–	–	–
Increased spasticity	Yes		Yes	–	–	–
Autonomic hyperreflexia (also called dysreflexia)	Yes	Yes (occurrence of new or increased autonomic dysreflexia [perspiration, bradycardia, increased blood pressure])		–	–	–
Cloudy, dark, and/or foul-smelling urine	Yes		Yes	–	–	–
Feeling unwell, lethargy, increased perspiration, or uncomfortable feeling	Yes		Yes (reflex perspiration)	–	–	–
Changes in need to urinate, frequency of urination, and incontinence		Yes	Yes (need to urinate, frequency of urination, and incontinence)	–	–	–
Physical signs of prostatitis, epididymitis, orchitis		Yes		–	–	–
Increased muscle spasms		Yes		–	–	–
Other				–	–	Any mention of UTI or related term
Number of criteria required	3	2	2	2	2	1
Comment	Bacteriuria, pyuria, and ≥1 symptom required	Bacteriuria and either pyuria or ≥1 symptom required	Bacteriuria and ≥1 symptom required	Both bacteriuria and pyuria required	Both bacteriuria and pyuria required

*If asymptomatic, two consecutive urine cultures (>24h apart) each >10⁵CFU/mL of the same microorganism.

Abbreviations: CFU, colony forming unit; CMS, Centers for Medicare and Medicaid Services; NIDRR, National Institute on Disability and Rehabilitation Research; US, United States; UTI, urinary tract infection; WBC, white blood cells.

Table 2 Baseline demographic and clinical characteristics.

Characteristics	N (%)
Age group, years
18–29	14 (19.2)
30–39	11 (15.1)
40–59	22 (30.1)
60–69	9 (12.3)
≥70	11 (15.1)
Missing/Unknown	6 (8.2)
Sex
Female	11 (15.1)
Male	56 (76.7)
Missing	6 (8.2)
SCI cause
Accident-related	47 (64.4)
Others	20 (27.4)
Missing	6 (8.2)
SCI Grade
A or B	47 (64.4)
C or D	20 (27.4)
Missing	6 (8.2)
SCI Location*
C1-C4	6 (8.2)
C5-C8	16 (21.9)
L1-L5	15 (20.6)
S1-S5	3 (4.1)
T1-T12	36 (49.3)
Missing	7 (9.6)
Smoking status
Smoker	22 (30.1)
Non-smoker	18 (24.7)
Missing/Unknown	33 (45.2)
Alcohol use
Alcohol user	21 (28.8)
Non-user	21 (28.8)
Missing/Unknown	31 (42.4)
Conditions noted during baseline period*
Benign prostate hyperplasia	3 (4.1)
Coronary artery disease	1 (1.4)
Diabetes mellitus	4 (5.5)
Liver disease	4 (5.5)
Kidney disease	4 (5.5)
Urologic disease	30 (41.1)
Asymptomatic bacteriuria	19 (26.0)
Urinary tract infection	19 (26.0)
Any infection	22 (30.1)
Baseline voiding method(s)*
Indwelling catheter	63 (86.3)
IFK	23 (31.5)
Other methods	4 (5.5%)
Baseline presence of pathogens	22 (30.1%)

Abbreviations: C, cervical; IFK, intermittent catheterization performed by a family member or caregiver; L, lumbar; S, sacral; SCI, spinal cord injury; T, thoracic.

*Categories are not mutually exclusive; therefore, the sum of categories could exceed 100%.

Figure 2 Number of pathogens identified during baseline and follow-up periods.

Figure 3 Incidence of UTI, by definition. Abbreviations: CMS, Centers for Medicare and Medicaid Services; EAU, European Association of Urology; NIDRR, National Institute on Disability and Rehabilitation Research; US, United States; UTI, urinary tract infection.

Table 3 Incidence of UTI during the three-month follow-up period.

Definitions	N (%) with UTI	Months of follow-up	UTI per 100 PMs
NIDRR definition	10 (13.7%)	187.7	5.33
CMS definition	25 (34.2%)	183.8	13.6
Togan definition	20 (27.4%)	186.2	10.74
EAU definition	24 (32.9%)	186.4	12.87
Burgdörfer definition	21 (28.8%)	189.6	11.08
Any mention of the term “UTI”	33 (45.2%)	145.6	22.66
Any of the above	42 (57.5%)	133.5	31.46

Abbreviations: CMS, Centers for Medicare and Medicaid Services; EAU, European Association of Urology; NIDRR, National Institute on Disability and Rehabilitation Research; PM, patient-month; US, United States; UTI, urinary tract infection

Table 4 Concordance between definitions of UTI.

	NIDRR definition	CMS definition	Togan definition	EAU definition	Burgdörfer definition	Any mention of the term UTI
NIDRR definition	10	10	10	10	10	8
CMS definition	10	25	20	21	21	18
Togan definition	10	20	20	16	16	15
EAU definition	10	21	16	24	21	17
Burgdörfer definition	10	21	16	21	21	16
Any mention of the term UTI	8	18	15	17	16	33

Abbreviations: CMS, Centers for Medicare and Medicaid Services; EAU, European Association of Urology; NIDRR, National Institute on Disability and Rehabilitation Research; US, United States; UTI, urinary tract infection.

Table 5 Causal pathogens associated with UTI during follow-up.

Causal pathogen	N = 42
Specific pathogens	N (%)
Enterococcus spp.	7 (16.7%)
Escherichia coli	20 (47.6%)
Klebsiella pneumoniae	21 (50.0%)
Proteus mirabilis	2 (4.8%)
Pseudomonas spp.	6 (14.3%)
Staphylococcus spp.	5 (11.9%)
Other pathogens*	34 (81.0%)
Any pathogen	41 (97.6%)
Any ESKAPE pathogens	31 (73.8%)
Etiology of UTI
Monomicrobial	7 (16.7%)
Polymicrobial	34 (81.0%)
No pathogen identified	1 (2.4%)

Abbreviations: ESKAPE, Enterococcus, Staphylococcus, Klebsiella, Acinetobacter, Pseudomonas, and Enterobacter spp.; UTI, urinary tract infection.

*Other pathogens include any nonspecific bacteria, Providencia, Serratia, Stenotrophomonas, Morganella, Enterobacter, Acinetobacter, and Citrobacter species.

Table 6 Distribution of antibiotics used to treat UTI during follow-up.

	NIDRR definition (N = 10)	CMS definition (N = 25)	Togan definition (N = 20)	EAU definition (N = 24)	Burgdörfer definition (N = 21)	Any mention of the term UTI (N = 33)	Any of the 6 definitions (N = 42)
	N (%)	N (%)	N (%)	N (%)	N (%)	N (%)	N (%)
Any antibiotic	9 (90.0%)	21 (84.0%)	19 (95.0%)	20 (83.3%)	17 (81.0%)	32 (97.0%)	38 (90.5%)
No antibiotic	1 (10.0%)	4 (16.0%)	1 (5.0%)	4 (16.7%)	4 (19.1%)	1 (3.0%)	4 (9.5%)
Monotherapy	3 (30.0%)	7 (28.0%)	6 (30.0%)	9 (37.5%)	7 (33.3%)	11 (33.3%)	14 (33.3%)
Polypharmacy	6 (60.0%)	14 (56.0%)	13 (65.0%)	11 (45.8%)	10 (47.6%)	21 (63.6%)	24 (57.1%)
Specific antibiotic
Carbapenem	2 (20.0%)	2 (8.0%)	2 (10.0%)	2 (8.3%)	2 (9.5%)	5 (15.2%)	5 (11.9%)
Cephalosporin	1 (10.0%)	6 (24.0%)	6 (30.0%)	4 (16.7%)	3 (14.3%)	6 (18.2%)	8 (19.1%)
Ciprofloxacin	7 (70.0%)	16 (64.0%)	14 (70.0%)	15 (62.5%)	14 (66.7%)	21 (63.6%)	23 (54.8%)
Nitrofurantoin	2 (20.0%)	9 (36.0%)	8 (40.0%)	6 (25.0%)	5 (23.8%)	11 (33.3%)	14 (33.3%)
Aminoglycoside	0 (0.0%)	0 (0.0%)	0 (0.0%)	0 (0.0%)	0 (0.0%)	1 (3.0%)	1 (2.4%)
Clindamycin	0 (0.0%)	1 (4.0%)	0 (0.0%)	1 (4.2%)	1 (4.8%)	1 (3.0%)	1 (2.4%)
Colistin	1 (10.0%)	1 (4.0%)	1 (5.0%)	1 (4.2%)	1 (4.8%)	1 (3.0%)	1 (2.4%)
Sulfonamide	0 (0.0%)	1 (4.0%)	1 (5.0%)	1 (4.2%)	1 (4.8%)	4 (12.1%)	4 (9.5%)
Vancomycin	0 (0.0%)	1 (4.0%)	1 (5.0%)	1 (4.2%)	1 (4.8%)	2 (6.1%)	2 (4.8%)
Penicillins and penicillin combinations	4 (40.0%)	6 (24.0%)	6 (30.0%)	4 (16.7%)	4 (19.1%)	7 (21.2%)	9 (21.4%)
Other antibiotic*	3 (30.0%)	4 (16.0%)	4 (20.0%)	5 (20.8%)	4 (19.1%)	9 (27.3%)	10 (23.8%)

Abbreviation: CMS, Centers for Medicare and Medicaid Services; EAU, European Association of Urology; NIDRR, National Institute on Disability and Rehabilitation Research; UTI, urinary tract infection.

Note: Percentages based on subgroup of patients who experienced UTI during follow-up (n = 42).

*Other antibiotics include fosfomycin, fusidic acid, metronidazole, and rifampicin.