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There is no question in my mind that urinary tract infections are likely the largest concern for spinal cord patients – and rightly so. They can cause unusual incontinence, fever, weakness and worst of all, hospitalizations and potentially death. When your PCP’s computer starts to generate everybody’s recently ordered labs, an ambulatory urine culture is reported right after or before a spinal cord urine culture. They are two different animals, but that fact can fall through the cracks. YOU NEED TO SUPPLY THE BEST POSSIBLE SPECIMEN.
An ambulatory patient, that just urinates, can supply a “clean catch urine” which is the closest to a perfect specimen you will get. If you do intermittent catheterization, have a foley or suprapubic, or use an external catheter – specimens and how the urine is collected has a lot to do with how it is interpreted. The collection is such an important issue, please read this carefully. Never send a specimen collected from a Foley or suprapubic bed or leg bag (even if new) or an external catheter. They are “clean”, but they aren’t necessarily sterile. You want to provide as sterile a specimen as possible. I realize that will be impossible for many, because of their social situation, but a “good” urine specimen that sits in a refrigerator for a while is better than contaminated urine, collected and rushed to a lab. Your manipulated urine will always be different, and you must request your specimen to be evaluated as a manipulated urine. Your specimen is a different animal than an ambulatory urine. You must be your advocate. Here are the ways your urine is different:
1. The urine has been “manipulated”, whether it’s from an intermittent catheter, a Foley or suprapubic - a foreign object has been in that urine and CAN have an impact on how the culture looks.
2. It doesn’t come from a bladder that regularly “empties”. An ambulatory patient will urinate and have 5 to 10 mL left in the bladder, because the contraction of the bladder wall helps to complete the emptying maneuver. Some of your bladders may contract and others not at all. That allows dead bladder cells to build up in the bladder and show up as the “sediment” you all watch so closely. At times it is helpful because it may also include bacteria and WBCs which can cause an unusual odor. It can be an important sign, or it can be misleading when you drink less fluids.
3. In the case of Foleys and suprapubics – there’s a foreign body in the urine which can allow a random bacterium to attach to and use it as a base for more bacteria to pile on and multiply.
4. Bad samples – like the ones I asked you to avoid – are mixed in with all the other urine cultures and will be misinterpreted. If you do intermittent catheterization, you should collect the specimen with a closed system or at least a sterile catheter and sterile gloves, with a sterile prep pad. The Foley or suprapubic should be clamped shut, and the catheter end cleaned around the outside edge and inside edge with alcohol and let it dry. Then take the specimen. If that’s impossible you just do your best. Try to get help to collect a “good” specimen.
5. Your urine may be colonized with a friendly bug that just wants a warm, moist place to live. If you chase them out with unnecessary antibiotics, a more ominous bacteria will take their place and that causes problems. Remember – you don’t have a normal bladder and it would be unusual and misleading to have a negative culture.
Doing these things will allow your urine to be judged like ambulatory urine, which is the goal, unless your PCP can flag your specimen to be singled out. You should always get a two-part culture, which includes a urinalysis or (U/A) and culture. Information from these two tests should match or you will get unnecessary treatment. The other part that YOU need to do is an honest self- exam. Do I feel sick? Do I have a temperature – and yes, I know a lot don’t. Is my concern driven by the sediment I’m seeing? Try to learn from each experience so you’re not asking for unnecessary antibiotics. Your PCP will likely respond to your request. That usually includes ordering a culture and an antibiotic – and the cycle of overtreatment continues, with all the complications we’ve talked about, and one we haven’t – C-diff.
I realize physicians come under pressure to keep their lab costs down, but they really need to do a u/a (urinalysis) with the culture on spinal cord patients. You need as much substantiating information before you start treatment for a UTI. Is the nitrate and leucocyte esterase positive? Are the wbcs elevated? Do they see bacteria and what kind? This chapter has been devoted to how “manipulated” urine is special AND the importance of collecting the most sterile urine possible. This topic is singularly the one which will cause you the most problems. You will be damned if you do and damned if you don’t treat. The complications of unnecessary treatment can be almost as bad as avoiding treatment.
If you decide to treat an “iffy” situation, use something like Macrobid or if it’s a nonspecific gram – you can consider low dose Gentamycin, while ordering a repeat culture, which if accurate, will look worse in three days. Gentamycin goes through the body unmodified and will sit in the urine. You don’t have to achieve therapeutic serum doses and can safely use it. I would avoid it in known kidney disease. If the first culture was a false positive, no harm, no foul. Make sure whoever in your office speaks to the patient, asks if they have a fever, do they feel sick or is this a sediment diagnosis. I wish I had more sage advice but remember in this instance it may take a little more thought to avoid “do no harm”.
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