Meta-Analysis
Antimicrobial prophylaxis for urinary tract infection in persons with spinal cord dysfunction,☆☆,,★★,,♢♢,

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Abstract

Morton SC, Shekelle PG, Adams JL, Bennett C, Dobkin BH, Montgomerie J, Vickrey BG. Antimicrobial prophylaxis for urinary tract infection in persons with spinal cord dysfunction. Arch Phys Med Rehabil 2002;83:129-38. Objective: To assess the benefits and harms of antimicrobial prophylaxis to prevent urinary tract infections (UTIs) in persons with neurogenic bladders caused by spinal cord dysfunction. Data Sources: A broad search strategy with no language restriction was conducted of MEDLINE (1966-January 1998), EMBASE (1974-January 1998), and CINAHL (1982-July 1998) using the general search terms urinary tract, urinary tract infections, bacteriuria, paraplegia, quadriplegia, spinal cord injuries, multiple sclerosis, neurogenic bladder, and neuropathic bladder. Additional articles were identified by experts and by reviewing reference lists of articles obtained from searches. Study Selection: Criteria included human studies of adults and adolescents who had neurogenic bladder due to spinal cord dysfunction; the studies had to address antimicrobial prophylaxis of UTI and include bacteriuria or UTI as an outcome. We excluded any study that was clearly not a controlled trial or that only included children under the age of 13 years. Two reviewers independently abstracted data, and disagreements were resolved by consensus. Data Extraction: Two reviewers independently abstracted data, and disagreements were resolved by consensus. Studies were graded by 1 project investigator according to quality criteria developed by Jadad and Schulz. Data Synthesis: The sizes of the effect of antimicrobial prophylaxis on weekly infection rates from 15 trials that met the inclusion criteria were pooled by using a random effects model. Antimicrobial prophylaxis did not significantly decrease symptomatic infections. Prophylaxis was associated with a reduction in asymptomatic bacteriuria among acute patients (<90d after spinal cord injury; P <.05); 1 patient would require 3.7 weeks of treatment on average to prevent 1 asymptomatic infection. For nonacute patients, the reduction approached statistical significance (P =.06). Prophylaxis resulted in an approximately twofold increase in antimicrobial-resistant bacteria. Conclusions: The regular use of antimicrobial prophylaxis for most patients who have neurogenic bladder caused by spinal cord dysfunction is not supported. A clinically important effect, however, has not been excluded. Future research should focus on randomized trials in those patients who have recurrent UTIs that limit their daily functioning and well-being. © 2002 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation

Section snippets

Literature search

We searched MEDLINE (1966-January 1998) and EMBASE (1974-January 1998) databases, using the search terms urinary tract, urinary tract infections, bacteriuria, paraplegia, quadriplegia, spinal cord injuries, multiple sclerosis, neurogenic bladder, and neuropathic bladder (free text term); case reports and animal studies were excluded. We also searched CINAHL (1982-July 1998), using analogous terms. No language restriction was applied in any search, nor was the “grey” literature such as letters

Search

The literature search yielded 4998 nonoverlapping titles from MEDLINE and EMBASE, and 255 titles from CINAHL. After reviews of titles, abstracts, and full-length articles, a total of 28 studies were identified as potentially relevant. A reference list search of those 28 articles and a survey of experts identified an additional 6 studies. Nineteen studies were excluded from the meta-analysis because they did not meet the final inclusion criteria. Figure 1 illustrates the search results, and

Clinical conclusions

Because of the high frequency of UTI or bacteriuria in persons with neurogenic bladder, assessment of the impact of prophylactic antimicrobial treatment is an important issue. Our meta-analysis of 15 controlled clinical trials does not support the claim that antimicrobial prophylaxis is associated with a reduced number of symptomatic infections among populations that have been studied. However, our analysis showed that antimicrobial prophylaxis is associated with a reduction in bacteriuria

Conclusions

Antimicrobial prophylaxis may reduce UTI among certain subgroups that our analysis was unable to investigate. In particular, prophylactic therapy may help reduce the number of infections among persons who suffer from frequent, disabling infections. This subgroup did not appear to be the target population in any of the studies we identified. Future research should focus on randomized, controlled trials in the subgroup of patients who have frequent, recurrent UTIs that limit their daily

Acknowledgements

We are grateful to Mayank Pathak, MD, Kenneth Clark, MD, Frank Lan, Michele Maines, Jeri Jackson, Zachary Edmonds, Scott Kwok, Annie Lee, and Sharon Koga for superb project assistance. Roberta Shanman, MLS, masterfully conducted the literature searches, and Caren Kamberg, MS, MPH, directed aspects of the identification of relevant literature. Tamara Breuder provided editing assistance. We also acknowledge the persons who served as advisors or reviewers for our evidence report. We also thank the

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    This article is based on research conducted by the Southern California Evidence-Based Practice Center/RAND, under contract with the Agency for Healthcare Research and Quality (contract no. 290-97-001). The authors are responsible for its contents. No statement in this article should be construed as an official position of the Agency for Healthcare Research and Quality or of the US Department of Health and Human Services.

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    No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit upon the author(s) or upon any organization with which the author(s) is/are associated.

    Reprint requests to Sally C. Morton, PhD, RAND, PO Box 2138, 1700 Main St, Santa Monica, CA 90407-2138, e-mail: [email protected].

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