Antibiotic Prophylaxis of UTIs

Author Year
Country
Score
Research Design
Total Sample Size

Methods Outcome
Morton et al. 2002
USA
Systematic Review
N=15 studies
Population: Acute studies=8 (patients with SCI<90 days ago; n=510): Treatments: trimethoprim, sulfamethoxazole, neomycin, polymiyxin B, nitrofurantoin, methenamine hippurate, methenamine madelate, hemiacidrin, ascorbic acid.
Nonacute studies=7 (patients with SCI>90 days ago (n=356): Treatments: nitrofurantoin, methenamine, mandelate, ammonium chloride, sulfamethoxazole, trimethoprim, ciprofloxacin, ascorbic acid.
Treatment: Literature search of Medline (1966- January 1998), Embase (1974-January 1998), and cinahl (1982-July 1998).
Outcome Measures: Symptomatic Urinary tract infections (SUTI), asymptomatic bacteriuria count.
  1. Antimicrobial prophylaxis did not significantly decrease SUTIs in either acute or nonacute patients (p>0.05).
  2. Antimicrobial prophylaxis reduced asymptomatic bacteriuria in acute patients (p<0.05), and nonacute patients (p=0.06) but the reduction was not significant in either.

Darouiche et al. 1994
USA
RCT
PEDro=9
N=40

Population: SCI Inpatients: Treatment group: Mean age: 52.9 yr; Gender: males=18, females=0; Placebo group: Mean age: 46.9 yr; Gender: males=22, females=0.
Treatment: Double blind comparison of 500mg of ciprofloxacin bid versus placebo bid for 3 d prior to urodynamic testing.
Outcome Measures: Incidence of urinary tract infection (UTI) (culture), bacteriuria, pyuria, adverse events collected prior and 3-5 d post urodynamic testing.
  1. 3 patients in the placebo group and none the patients in the treatment group developed symptomatic UTI but this was not significant (p=0.24).
  2. No adverse effects were reported.

Biering-Sorensen et al. 1994
Denmark
PEDro=8
RCT
N=21

Population: SCI with neurogenic bladder: Mean age: 38 yr; Gender: males=18, females=3.
Treatment: Cross-over comparison of 6 mo ciprofloxacin (100mg/night) versus placebo prophylaxis.
Outcome Measures: Number of urinary tract infections (UTIs), urine and fecal cultures, side effects collected over 6 mo periods.
  1. Ciprofloxacin versus placebo prophylaxis (6 mo): number of UTIs greatly reduced with 5 versus 59 (p<0.00005)
  2. 1 instance of ciprofloxacin resistant E. coli found in the feces of 1 cipro patient
  3. No severe side effects.
Gribble & Puterman 1993
Canada
RCT
PEDro=8
N=129
Population: Acute (<30 d) SCI: Mean age: 38 yr; Gender: males=112, females=17.
Treatment: Efficacy of trimethoprim-sulfamethoxazole (TMP-SMX; TMP 40 mg, SMX 200mg) for UTI prophylaxis in acute SCI, during the first 4 mo of intermittent catheterization (IC). Breakthrough bacteriuria treated with conventional antimicrobial therapy and prophylaxis was continued.
Outcome Measures: Clinical: weekly rectal and urethral swab and urine cultures collected for 4 mo or until hospital discharge.
  1. TMP-SMX more efficacious than placebo (P) prophylaxis:
  • Lower incidence/freq/relapse of bacteriuria and symptomatic UTI in males (p<0.003 /0.0001/0.0001 and 0.0003).
  • Similar trends in women.

Other results:

  • Adverse events similar between groups
  • ≥1 TMP-SMX-resistant bacteriuria in all P subjects by yr 3.
  • Rectal/urethral swab TMP-SMX-resistant organisms-both grps.
  • TMP-SMX UTI prophylaxis effective in acute SCI/IC but emergent TMP-SMX-resistance limits usefulness.

Salomon et al. 2009
France
Pre-Post
N=6

Population: Mean age: 34 yr; Gender: males=0, females (pregnant)=6; paraplegic=4, tetraplegic=2.
Treatment: Weekly oral cyclic antibiotic (WOCA) program.
Outcome Measures: Urinary tract infection (UTI) rate, birth weight, obstetric and neonatal characteristics.
  1. Significant reduction in UTI rate. Only 2 patients had a UTI compared to before the treatment with 6 UTI per yr per patient (p<0.001).
  2. No complications were observed during the delivery.
  3. All newborns were born healthy with a mean weight of 3180g.
Salomon et al. 2006 France
Pre-Post
N=38
Population: SCI with neurogenic bladder and undergoing intermittent catheterization; Mean age: 45.9 yr; Gender: males=22, females=16; daily catheterizations=6.
Treatment: Weekly oral cyclic antibiotic (WOCA): Wk 1-one antibiotic+wk 2 another antibiotic (over 2 yr). Antibiotic choice based on urine culture results: amoxicillin 3000mg; trimethoprim/ sulfamethoxazole 320-1600mg; fosfomycin trometamol 6000mg; nitrofurantoin 300mg; cefixime 40mg.
Outcome Measures: Number of urinary tract infections (UTIs) with weekly cultures for first 3 mo and monthly thereafter over 2 yr.
  1. Before/after WOCA programme:
  • Reduced symptomatic UTIs/ pt/yr from 9.4 to 1.8, p<0.01.
  • Reduced febrile UTI/pt/yr from 0.75 to 0.31, p<0.04.
  • Reduced hospitalization days from 4 to 1.2 d/patient, p<0.01.
  • Decreased antibiotic consumption correlated with decreased incidence of UTIs over the course of the study.
Sandock et al. 1995
USA
Prospective Controlled Trial
N=43
Population: SCI inpatients; Treatment group: Mean age: 46 yr; Gender: males=20; Level of injury: lumbar=2, paraplegic=5, tetraplegia=13; Mean time post-injury=9.2 yr; Control group: Mean age: 58.3 yr; Gender: males=23; Level of injury: lumbar=3, paraplegic=8, tetraplegic=12; Mean time post-injury=14.9 yr.
Treatment: Comparison of 400mg trimethoprim-sulfamethoxazole (TMP-SMX) daily versus no treatment over a minimum of 3 mo.
Outcome Measures: Incidence of asymptomatic bacteria, prevalence of urinary tract infection UTI, types of bacteria present. Urine cultures weekly.
  1. No significant difference was found between the control and treatment groups in:
  • Incidence of asymptomatic bateriuria.
  • Percent of cultures with asymptomatic bacteriuria (p>0.1).
  • Incidence of symtomatic UTIs per week (p>0.5).
  • Percentage of TMP-SMX resistant UTIs (p>0.5).
  • Types of bacteria present.

2.   The control group was signficantly lower than the treatment group in:

  • Percent of cultures with TMP-SMX resistant asymptomatic bateriuria (p<0.05).
Reid et al. 1994a
Canada
Prospective Controlled Trial
N=14
Population: SCI inpatients with intermittent catheterization: Age range 20-66 yr; Gender: males=11, females=3.
Treatment: Comparison of co-trimoxazole (TMP-SMX 160/800 mg bid) versus no prophylaxis. Symptomatic urinary tract infections (UTIs) were treated with appropriate antibiotic and a separate analysis was done on effect of fluoroquinolones (ciprofloxacin, ofloxacin and norfloxacin) on bladder biofilm bacteria.
Outcome Measures: Infection rate, extent of biofilm formation, level of bacterial adhesion; urine samples collected for culture and sonication for 8 wk.

1.   TMP-SMX versus non-prophylaxis prophylaxis subjects:

  • 54% versus 68% infection rate (not significant; no p value reported)
  • E coli replaced by E faecalis as dominant uropathogen with TMPSMX use.
  • 39±42 versus 44±49 adherent bacteria/bladder cell (not significant; no p value reported)

2.   Laboratory results for treatment effect of fluoroquinolones versus TMP-SMX prophylaxis on biofilms:

  • Reduced adhesion counts in favour of Fluoroquinolone versus TMP-SMX (63% versus 44%, no p value).
  • 92%, 71%, 56% biofilm reduction with ciprofloxacin, ofloxacin & norfloxacin.
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