Donna S. Gilmore

Effect of External Urinary Collection System on Colonization and Urinary Tract Infections with Pseudomonas and Klebsiella in Men with Spinal Cord Injury

Urinary tract infection of men with spinal cord injuries has been associated with a high incidence of colonization of the patients with gram-negative bacilli. We have examined the factors influencing colonization of 119 patients with Pseudomonas and Klebsiella and studied methods of reducing this colonization. The urethra, perineum, rectum, and drainage bag of all patients were cultured on selective media at two week intervals until discharge. The use of the external urinary collection system (EUCS) was discontinued in a group of patients at night, in an attempt to reduce colonization. Pseudomonas and Klebsiella were isolated from one or more body sites in 65 percent and 69 percent of total culture days. The urethra, perineum, rectum, and drainage bags were reservoirs of Pseudomonas and Klebsiella in men with spinal cord injuries, even in the absence of urinary tract infections. The EUCS proved to be an important factor influencing colonization. Pseudomonas and Klebsiella colonization was higher in patients using the EUCS. Removal of the EUCS at night reduced urethral colonization with Pseudomonas, but did not significantly reduce urethral colonization with Klebsiella. The prevalence of bacteriuria with Pseudomonas and Klebsiella was not significantly influenced by the use of the EUCS.

Effect of antiseptic agents on skin flora of the perineum of men with spinal cord injury.

Male patients with spinal cord injury are frequently colonized with P. aeruginosa and K. pneumoniae on the perineum. Regular bathing with bar soap has not influenced this colonization. We have attempted to remove these bacteria using antiseptic agents. The number of P. aeruginosa, K. pneumoniae and total aerobic bacteria on the perineum and the penile shaft was determined before and after cleaning with bar soap, chlorhexidine, povidone-iodine and pHresh. Povidone-iodine and chlorhexidine had no advantage over bar soap or pHresh in the removal of P. aeruginosa or K. pneumoniae from the perineum of patients with spinal cord injury.

Increased Frequency of Large R-Plasmids in Klebsiella pneumoniae Colonizing Patients with Spinal Cord Injury

From 1978 to 1988 strains of gentamicin-susceptible (Gms) and gentamicin-resistant (Gmr) Klebsiella pneumoniae were saved from annual surveillance cultures of the perineal region of patients with spinal cord injury (SCI). Of 38 strains selected for further study (24 Gms and 14 Gmr), there were 23 different serotypes (two nontypable). Fourteen Gms as well as 14 Gmr strains displayed no common plasmid patterns, but all contained a large plasmid of 168-208 kb. Among the 14 Gmr strains, nine had large conjugative plasmids of approximately the same size (166-193 kb), which conferred to a susceptible Escherichia coli host an identical resistance pattern: ampicillin, chloramphenicol, gentamicin, piperacillin, trimethoprim-sulfamethoxazole, tetracycline, and tobramycin. Of the nine transconjugants, eight contained a single plasmid. One transconjugant contained a 168- and 80-kb plasmid. Restriction endonuclease digestion patterns of the R-plasmids revealed minimal similarity. We conclude that, during a 10-year period, different large R-plasmids have spread among multiple serotypes of K. pneumoniae in spinal cord injury (SCI) patients in one rehabilitation hospital. We hypothesize that other genes located on large, R-, and non-R-plasmids may confer an additional advantage for colonization by K. pneumoniae in SCI patients.

Klebsiella pneumoniae colonization in patients with spinal cord injury

Klebsiella pneumoniae colonization of 53 patients with spinal cord injury was studied. Cultures of multiple body sites from patients, the environment, food, and hospital personnel were obtained. K. pneumonaie was cultured from one or more body sites in 46% of male patients. Significant bacteriuria was found in 10% of male patients. Positive cultures of the urethra and perineum for K. pneumoniae were significantly associated with the use of the external condom catheter (p less than 0.05, Fishers exact test). K. pneumoniae colonization increased with length of stay in the hospital. Serotype 64, the predominant serotype found, was isolated only from patients who had been in the hospital for at least 4 wk and primarily in those patients using the external condom catheter. Urinary drainage bags were frequently colonized with K. pneumoniae at a time when the patients did not have significant bacteriuria. Colonized male patients were found to be the primary reservoir of K. pneumoniae and may serve as the major source for cross-contamination.

Ceftazidime in treatment of urinary tractinfection in patients with spinal cord injury: Comparison with moxalactam

Ceftazidime was compared with moxalactam in the treatment of urinary tract infections in patients with spinal cord injury. Patients received ceftazidime or moxalactam, 500 mg twice daily for five days. Urine specimens were collected by urethral catheter. Adequate follow-up was obtained in 26 patients treated with ceftazidime and 13 patients treated with moxalactam. The infecting bacteria were not cultured in significant numbers from the urine of any patients after two to four days of antibiotics, except for 1 patient who had Pseudomonas aeruginosa persisting in the urine while receiving ceftazidime. At five to nine days after completing antibiotic therapy, the cure rate was 42 percent for ceftazidime and 15 percent for moxalactam. The rate of reinfection was significantly lower in the ceftazidime group than the moxalactam group.

Pseudomonas urinary tract infection in patients with spinal cord injury.

Serum antibodies to P. aeruginosa were measured in 28 patients with spinal cord injury before and after the development of bacteriuria during their hospital rehabilitation. Serum IgG, IgA and IgM were measured against the infecting strain of P. aeruginosa isolated from the urine of each patient. After bacteriuria was detected, a significant increase (fourfold or greater) in IgG and/or IgA antibodies was found in nine patients (33%). This increase was significantly associated with leucocytosis. These observations indicate that bacteriuria with P. aeruginosa in patients with spinal cord injury is associated with a serum antibody response in a significant number of patients, indicating tissue invasion by this microorganism.

The effects of antiperspirant on the perineal skin flora of patients with spinal cord injury

The relationship of pH and moisture to Pseudomonas aeruginosa and Klebsiella pneumoniae colonization of the perineal skin was studied in male patients with spinal cord injury. The increased pH of the perineal skin was significantly associated with the presence of P. aeruginosa but not other bacterial species. No correlation between colonization and moisture or pH and moisture was found. An antiperspirant produced a significant reduction in the number of total aerobic bacteria, total gram-negative bacilli, P. aeruginosa and K. pneumoniae over a 24-h period. Long-term use of the antiperspirant for 10 days did not alter the persistence of P. aeruginosa of the same serotypes on the perineum.

Category 1, 2, 3 and 4 A Procedure-Oriented Isolation System

A procedure-oriented isolation system, Category 1,2, 3, and 4, was introduced at a 547-bed, acute and rehabilitative medical center. The system consisted of four categories of isolation which followed a numerical sequence that represented the necessary attire needed to complete the procedure. After 1 year of use, personnel compared the procedure-oriented system with the previously-used system (Strict, Respiratory, Wound and Skin, Enteric, and Limited Barrier). Personnel found the procedure-oriented system easier to understand (84%) and follow (83%). Seventy-six percent felt their isolation techniques had improved with the new system. A reduction in the cross-infection rate with methicillin-resistant Staphylococcus aureus did coincide with the use of the new isolation system, however, no causal relationship was established. The Category 1, 2, 3, and 4 isolation system was well received by personnel and was found to be an effective alternative to the previous, more complicated system used in this setting. Further evaluation of this system in other settings would seem warranted.

Cefsulodin in treatment of Pseudomonas urinary tract infection in patients with spinal cord injury. Comparison with aminoglycosides.

Male patients with spinal cord injury and urinary tract infection with Pseudomonas aeruginosa were treated with cefsulodin (1.0 or 1.5 Gm) every six hours or an aminoglycoside (amikacin 5 mg/Kg or tobramycin 1 mg/Kg) every eight hours for seven days. The study was discontinued after treating 6 patients with aminoglycosides because of the poor results with these antibiotics. At five to nine days after completing treatment P. aeruginosa was eliminated from the urine of 12 to 15 patients (80%) treated with cefsulodin and 3 of 6 patients (50%) treated with an aminoglycoside. When examined at four to six weeks 5 of 15 (33%) of the cefsulodin group had persistent infection or relapse, while 5 of 6 (83%) infections treated with an aminoglycoside either persisted or relapsed. Cefsulodin was discontinued in 1 patient, known to be allergic to penicillin, because of hypersensitivity resulting in periorbital edema and rash. No other serious side effects were noted with cefsulodin or the aminoglycosides. These results indicate that cefsulodin is an effective antibiotic in the treatment of urinary tract infection with P. aeruginosa in patients with neurogenic bladder resulting from spinal cord injury and confirmed previous observations of a poor response of Pseudomonas urinary tract infection to aminoglycosides in this group of patients.