By Bob Vogel
Urinary tract infections caused by antibiotic-resistant bacteria are on the increase among wheelers. A primary cause is the indiscriminate use of antibiotics, which results in vulnerability to resistant infections not just in the bladder but throughout the body. Not surprisingly, people with neurogenic bladders due to spinal cord injury, stroke or multiple sclerosis are at greater risk for antibiotic-resistant infections than the general population.
What is indiscriminate use? According to urologist William Blank, of the State University of New York Health Science Center in Brooklyn, it takes three main forms--using antibiotics when you're not sure you really have a significant UTI, using antibiotics that don't target the specific bacteria you have, and not taking the full course of antibiotics prescribed.
Fact: If you catheterize, you will always have bacteria in your urine. Resistant bacteria can form if you use an antibiotic again and again with bacteria present in the urine but no physical signs of infection, if you use antibiotics repeatedly to treat full-blown infections, or if you stop taking prescribed antibiotics before all the targeted bacteria are killed. In all three cases, some of the bacteria can survive, reproduce and eventually become a completely resistant strain.
The first step in avoiding resistant infections is to get back to bladder basics. Remember them? Keep your hands and catheter clean, drink plenty of water and empty your bladder before it gets too full (an average adult bladder is full when it contains 400 to 700 cc of urine). When your bladder gets too full, its walls stretch and become damaged, more susceptible to bacteria. Stagnant urine then gives the bacteria a chance to attach to the bladder wall and start an infection.
Sterile Procedure Made Easy
What if you use good bladder management and still get frequent UTIs? You might want to try closed system catheters, which have a sterile, pre-lubed catheter in a clear collection bag with an introducer tip on one end. This tip is a silicone sheath, slightly over five-eighths of an inch in length, that slides into the urethra. Then the catheter passes through the sheath to the main part of the urethra and the bladder. Since most bacteria that cause UTIs are near the urethral entrance, the introducer tip prevents them from being carried to the bladder by the catheter.
Closed systems are also touchless. If you use them used properly, your hands--and any bacteria on them--never come in contact with the catheter. And the collection bag enables the closed system to be discreetly used almost anywhere, so you can reduce the risk of letting your bladder get too full while looking for a bathroom. Markers on the side of the collection bag make it easy to monitor volume and stay within the 400-700 cc range. A 1997 clinical trial at UCLA's Department of Urology concluded that introducer-tip catheters "decreased urinary tract infections in hospitalized men with spinal cord injury on intermittent catheterization."
"I was having problems with infections when I was using straight catheters," says Thomas Henry, 58, of Sanford, Maine. "I switched to a closed system catheters a little over a year ago because I heard they might help out, and they have. I've only had one infection since." Henry has multiple sclerosis, and finds the closed system easier to use with his limited hand coordination. He also feels that closed system catheters greatly reduce contamination from public bathrooms.
Shannon Francklin, 38, a C5-7 quad from Atlanta, has had good results with closed systems. "I've been in a chair for 13 years," she says, "and I switched to closed system catheters three years ago mainly for the convenience. I travel a lot both for work and for wheelchair racing. I like the fact that I can use them anywhere. I've also noticed since using the system that my rate of infection is down to one a year or less."
"It is a common experience that when people who have had trouble with recurrent UTIs switch over to a closed system, they have a drastic reduction in infection," adds Blank. He believes that anybody who has had more than two or three documented UTIs a year, has been hospitalized for pyelonephritis (kidney inflammation) or has had a serious infection is a candidate for closed system catheters.
The fact that closed systems can
reduce infection rates has not been lost on Medicare. In a recent ruling,
Medicare announced that it will cover the closed systems provided there
is proper documentation. You automatically qualify if you have reflux (urine
that backs up into the kidney) or are immune-suppressed or pregnant. You
also qualify with two or more documented infections during a 12-month period.
A "documented infection" means you have symptoms such as increased incontinence or muscle spasms, autonomic dysreflexia, fever, pyuria (pus in the urine) or signs of infection in other organs (e.g., the kidneys or prostate) combined with a cultured bacteria count of 10,000 or higher. The message here is that if you feel a UTI coming on, get a culture and have any other symptoms documented by your doctor. Otherwise your insurance is likely to restrict you to the "four catheters a month" regime.
I've benefited from the Medicare ruling myself. A T10 paraplegic for 15 years, I had a long bout with recurrent UTIs. About five years ago I switched to a closed system and my rate of UTIs dropped. But just prior to the Medicare ruling, my coverage for closed system catheters was canceled. I was cut back to four conventional catheters a month and had to pay for the rest out of my own pocket. Then came the new guidelines, my prior UTIs were duly documented, and my closed system catheters were once again covered.
So the message repeats itself: If you have a UTI, make sure it's documented by letting your doctor know.
Private Insurance Coverage
Private insurers have also seen the light. If you have been turned down for closed system catheters in the past, it's a good idea to check back from time to time. Ernie Espinoza, 33, a T4 para from Paramount, Calif., had been using straight catheters and getting a UTI every three or four months. "I asked my HMO about going on a closed system catheter but they wouldn't pay for it," he says. "By chance the HMO changed the pharmacy provider. When I found out they carried closed system catheters, I asked for some and I got them. That was nine months ago and it has been a complete turnaround. I've only had one UTI."
Despite your best bladder management, UTIs can still happen. How do you know when you really have an infection and it's time to knock it out with antibiotics? Start with the right doctor.
"I see spinal cord injury patients going to their regular doctor, not a rehabilitation specialist," says Jeff Rosenbluth, physical medicine and rehabilitation specialist at the VA Medical Center in Seattle. "They get treated with antibiotics for questionable UTIs and that has a lot to do with creating antibiotic resistance." Rosenbluth says treating UTIs in people with spinal cord injuries requires a balanced approach--examining the urine, culturing it to determine what antibiotics to use, and identifying actual, not just potential, symptoms. "These factors are what should be used to determine when to take antibiotics," says Rosenbluth.
Blank suggests finding a doctor who understands both your disability and UTIs and is willing to work with you as a team. He offers this safe shortcut: "I give my patients who are at risk for a UTI a prescription to have a urine culture done and a couple of sterile urine cups. That way if they feel a UTI coming on they can drop off a sample." For about $30 in lab tests, plus noting physical symptoms, your doctor can make an educated decision on whether or not you need antibiotics and can identify the right drug for your infection.
Of course you are the other half of the team. It's your job to listen to your body and act upon what it's telling you--to get some rest, drink more fluids, catheterize more often or get a urine culture. It's your body, and it's up to you to keep it healthy.
Closed-System Catheter Resources