How do rehabilitation services impact infection control?
Gastrointestinal: Rehabilitation Services contribute guidelines related to the treatment of infectious diseases in unique patient populations, namely individuals with neurogenic bowels from upper or lower motor neuron disorders (e.g., spinal cord injury, brain injury or disease, multiple sclerosis, cerebral palsy, stroke, peripheral neuropathy, Parkinson’s disease).
Pulmonary: Rehabilitation Services contribute guidelines related to the prevention and treatment of infectious diseases in unique patient populations, namely individuals with impaired pulmonary function (cervical and thoracic spinal cord injury, brain dysfunction, neuromuscular disease, frailty, pulmonary disease), elevated risk for aspiration (brainstem dysfunction, altered level of arousal and awareness, head and neck surgery, high cervical spinal cord injury, prior history of dysphagia, sialorrhea), and skin and oral cavity colonization from prolonged lengths of stay on acute and rehabilitation units (severe trauma, spinal cord injury).
Skin: Rehabilitation Services contribute guidelines related to the prevention and treatment of infectious diseases in unique patient populations, namely individuals with prolonged lengths of stay on acute and rehabilitation units (severe trauma, spinal cord injury) and with elevated risk for skin breakdown (pressure ulcer).
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Genitourinary: Rehabilitation Services contribute guidelines related to the treatment of infectious diseases in unique patient populations, namely individuals with neurogenic bladders from upper or lower motor neuron disorders (e.g., spinal cord injury, brain injury or disease, multiple sclerosis, cerebral palsy, stroke, peripheral neuropathy, Parkinson’s disease).
Those individuals at highest risk for skin colonization (skin, nares, anus, urethral meatus) with multidrug resistant organisms are those with trauma-related disability with severely elevated initial trauma severity scores, in particular those with spinal cord injury (SCI), those who are unable to care for themselves (e.g., infants, children, severely physically impaired), those exposed to other infected individuals, and those on prolonged antibiotic usage.
What elements of rehabilitation services are necessary for infection prevention and control?
Gastrointestinal: Specific criteria exist in regards to treatment of infections affecting the GI tract in individuals with spinal cord injuries, however they should apply to any individual who has impaired upper or lower motor neuron control of the GI tract (i.e., the large bowel).
Pulmonary: Standard rehabilitation protocols need to be followed to limit risk for aspiration-related infection in individuals with elevated risk. All individuals who are at risk for aspiration and aspiration-related pneumonia, whether due to cognitive issues (impulsivity, inappropriate oral habits, poor compliance), excessive salivation, oral motor dysfunction, swallowing dysfunction, inability to effectively cough or clear secretions, head and/or neck structural deficits, or pulmonary disease or disorders, should be fully evaluated by a speech and language pathologist (SLP) before being given any oral feeding or liquids. Modified barium swallows, interpreted by a SLP, are the gold standard for evaluation. Dietary restrictions that are recommended by SLP should be strictly adhered to. Regular oral care and pulmonary toilet should be incorporated into care on acute and rehabilitation units.
Skin: Specific criteria exist in regards to treatment of pressure ulcers to optimize healing and thereby reduce the risk of infection.
Genitourinary: Specific criteria exist in regards to treatment of infections affecting the GU tract in individuals with spinal cord injuries, however they should apply to any individual who has impaired upper or lower motor neuron control of the GU tract (i.e., the bladder).
Specific criteria exist in regards to treatment of individuals with spinal cord injury and neurogenic bladders who are maintained with indwelling catheters versus those managed with intermittent catheterization programs.
What are the conclusions of clinical trials or meta-analyses regarding rehabilitation services that guide infection control practice and policies?
Gastrointestinal:
Those individuals on rehabilitation units who are at elevated risk for infectious colitis and for multidrug resistant organisms colonizing the GI tract are those with trauma-related disability with severely elevated initial trauma severity scores, in particular those with spinal cord injury (SCI), those who are unable to care for themselves (e.g., infants, children, severely physically impaired), those exposed to other infected individuals, and those on prolonged antibiotic usage.
Individuals with disorders that affect the GI tract (i.e., neurogenic bowel), such as spinal cord injury, brain injury or disease, multiple sclerosis, cerebral palsy, stroke, peripheral neuropathy, Parkinson’s disease will have altered motility with an increased risk of infection and perforation.
GI Candidiasis incidence is higher in people with disabilities, such as nursing home (NH) patients and those with upper motor neuron syndromes (e.g., spinal cord injury, brain injury or disease, multiple sclerosis, cerebral palsy, stroke, Parkinson’s disease).
Patients with brain disorders (especially those affecting the brain stem) can have increased sialorrhea and/or dysphagia, which can increase the risk of aspiration, poor dentition and oral infections.
Persons dependent on others for oral care have higher incidences of plaque and gingivitis.
Individuals who require parenteral feeding, such as via Percutaneous Endoscopic Gastrostomy (PEG) tubes have an increased incidence of peptic ulcer disease, GI infections and upper GI bleeding.
Presence of diarrhea in acute care rehabilitation settings should alert clinician to test for clostridium difficile colitis.
Higher prevalence of GERD in patients with SCI, stroke and CP than in age-matched controls, which increases the risk of dysphagia and associated pneumonia. Approximately 45% of people with chronic SCI will have symptoms of reflux esophagitis, with associated increase in the risk of dysphagia and associated infection. Prophylactic treatment (proton pump or H-2 antagonist agents) utilized for first 3 months.
SCI predisposes patients to hypomotility of the bowel, gastric dilatation, increased incidence of cholelithiasis, and abnormalities related to transport, storage, and evacuation of the colon and rectum increasing risk of infection.
Acute SCI has higher incidence of paralytic ileus than non-SCI patients.
Patients with SCI are frequently colonized with MRSA in the perineum because they are referred from intensive care units from other institutions and have can have lengthy rehabilitation stays.
Following injury, insult or disease with resulting upper or lower motor neuron disorder (e.g., spinal cord injury, brain injury, multiple sclerosis, stroke, neuropathy, Parkinson’s disease) it is important to define neurologic level and completeness of injury, as well as the impact of the neurologic injury on the resulting neurogenic bowel (reflex bladder, spastic bladder, flaccid bladder, mixed bladder), as it defines management program and risks for infection.
In order to lower the risk of infectious colitis and other complications in neurogenic bowel, management includes
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Identifying the type of neurogenic bowel (reflex, spastic, flaccid, mixed) present initially and then when the injury recovery is stabilized (i.e., at 2-3 months)
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Initiating a bowel program that includes stool softener and GI stimulants daily, adequate hydration, and the use of digital stimulation, seated positioning and the gastrocolic reflex to encourage every other day stool evacuation
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Suppositories are only used if needed and are reserved until required and begun with the lowest strength and advanced to the highest strength to promote an efficient and consistent bowel program.
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Monitoring the success of the bowel program, the length of the bowel program, and any complications
Hand washing is an important deterrent in infection transmission among staff and patients on rehabilitation units.
Proper oral care including appropriate positioning, adequate nutrition and hydration, and maintenance of oral hygiene reduces pathogenic bacterial colonization and reduces risk of aspiration-related pneumonia.
Special adaptive equipment should be utilized to maximize ability to self-feed and to decrease the risks associated with requiring assistance to manage oral care.
Treatment for c.difficile colitis follows standard treatment protocol with Metronidazole or oral Vancomycin.
Autonomic dysreflexia (AD) affects SCI patients with injuries above the T6 level and is commonly caused by gastric dysmotility and infection. Symptoms of AD include pounding headache, systolic and diastolic hypertension (>20 mmHg increase), profuse sweating, cutaneous vasodilation with flushing of face, neck and shoulders (above level of injury), nasal congestion, papillary dilation and bradycardia and can lead to cerebral hemorrhage and even death.
Pulmonary:
Those individuals at highest risk for skin colonization (skin, nares, anus, urethral meatus) with multidrug resistant organisms and subsequent elevated risk of pneumonia following an aspiration event, are those with trauma-related disability with severely elevated initial trauma severity scores, in particular those with spinal cord injury (SCI), those who are unable to care for themselves (e.g., infants, children, severely physically impaired), those exposed to other infected individuals, and those on prolonged antibiotic usage.
Hand washing is an important deterrent in infection transmission.
Patients with brain disorders (especially those affecting the brain stem and those with altered levels of arousal or awareness) can have increased sialorrhea and/or dysphagia, which can lead to aspiration, poor dentition and oral infections that will elevate the risk of pneumonia.
Persons dependent on others for oral care have higher incidences of plaque and gingivitis, which increase the risk of an aspiration-related pneumonia. Proper oral care including positioning, adequate nutrition and hydration reduces pathogenic bacterial colonization and reduces risk of aspiration pneumonia. Special adaptive equipment can be utilized to maximize ability to self-feed and decrease the risks associated with requiring assistance to manage oral care.
Higher prevalence of GERD in patients with SCI, stroke and CP than in age-matched controls, which increases the risk of dysphagia and associated pneumonia. Approximately 45% of people with chronic SCI will have symptoms of reflux esophagitis, with associated increase in the risk of dysphagia and associated infection. Prophylactic treatment (proton pump or H-2 antagonist agents) utilized for first 3 months.
All individuals who are at risk for aspiration and aspiration-related pneumonia, whether due to cognitive issues (impulsivity, inappropriate oral habits, poor compliance), excessive salivation, oral motor dysfunction, swallowing dysfunction, inability to effectively cough or clear secretions, head and/or neck structural deficits, or pulmonary disease or disorders, should be fully evaluated by a speech and language pathologist (SLP) before being given any oral feeding or liquids. Modified barium swallows, interpreted by a SLP, are the gold standard for evaluation. Dietary restrictions that are recommended by SLP should be strictly adhered to. Regular oral care and pulmonary toilet should be incorporated into care on acute and rehabilitation units.
Following a suspected or observed aspiration event, clinical manifestations (e.g., pneumonia) may be delayed 24-48 hours, so close surveillance is warranted. Intensive oral care and pulmonary toilet is warranted for the at least the first 24 hours after a suspected event. A re-evaluation by SLP is indicated before recommencing oral feeding or liquids.
Systemic antibiotics are only indicated for individuals with clinical manifestations (e.g., fever, leukocytosis) or imaging (e.g., chest x-ray) evidence of pneumonia.
Tracheostomy tubes, including those with inflated balloons, do not reduce the risk of aspiration, and may increase the production and retention of oral secretions.
Skin:
Those individuals at highest risk for skin colonization with multidrug resistant organisms are those with trauma-related disability with severely elevated initial trauma severity scores, in particular those with spinal cord injury (SCI), those who are unable to care for themselves (e.g., infants, children, severely physically impaired), those exposed to other infected individuals, and those on prolonged antibiotic usage.
Those individuals at elevated risk for skin breakdown include those with; age >75 years, Spinal Cord Injury (SCI), prior history of skin breakdown, poor nutrition, incontinence, immobility, cognitive impairment (brain injury, stroke, dementia, delirium).
There are numerous protocols available to monitor skin for colonization, risk for pressure ulcer development and for the management of pressure ulcers. Consistent adherence to these protocols has been demonstrated to be effective, however compliance is often variable.
Systemic antibiotics do not have a role in skin colonization. Local use of bactericidal skin washes and isolation precautions for individuals on inpatient rehabilitation units with drug-resistant colonization is recommended.
For the management of pressure ulcers, systemic antibiotics are only recommended if there is evidence of cellulitis, the individual is demonstrating systemic infection (fever, leukocytosis) or is immunocompromised, or osteomyelitis is present.
Hand washing is an important deterrent in infection transmission.
Genitourinary:
Those individuals on rehabilitation units who are at elevated risk for urinary tract infection and for multidrug resistant organisms colonizing the GU tract are those with trauma-related disability with severely elevated initial trauma severity scores, in particular those with spinal cord injury (SCI), those who are unable to care for themselves (e.g., infants, children, severely physically impaired), those exposed to other infected individuals, and those on prolonged antibiotic usage.
Following injury, insult or disease with resulting upper or lower motor neuron disorder (e.g., spinal cord injury, brain injury or disease, multiple sclerosis, cerebral palsy, stroke, peripheral neuropathy, Parkinson’s disease). It is important to define neurologic level and completeness of injury, as well as the impact of the neurologic injury on the resulting neurogenic bladder (reflex bladder, spastic bladder, flaccid bladder, mixed bladder), as it defines management program and risks for infection.
In individuals with neurogenic bladder, UTI management depends on history, current symptoms and lab results.
There are various criteria that exist to guide UTI management: laboratory results (e.g., number of bacteria in specimen and leukocytes) and clinical symptoms (e.g., malodorous urine, changes in continence or bladder emptying pattern, fever, chills, change in pH indicative of specific bacteria).
Consensus conference of the National Institute on Disability and Rehabilitation Research (NIDRR) regarding colony count criteria for significant bacteriuria in SCI:
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≥10^2 cfu/ml for specimens from individuals on Intermittent Catheterization
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≥10^4 cfu/ml for clean void specimens from catheter-free males using condom collection devices
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any detectable concentration of uropathogens from indwelling catheters or suprapubic aspirates
The greatest risk for complicated UTI after an upper motor neuron injury is the need for an indwelling catheter
If only dipstick positive urine is cultured, many UTI’s are missed. Dipstick negative urine high NPV (96 & 99%; leukoesterase and nitrite production). Dipstick not recommended for asymptomatic patients
Most UTIs have no symptoms. Chills/fever indicative of pyelonephritis/infected calculus/renal/perinephric abscess
When an indwelling catheter is used:
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Asymptomatic bacteriuria should not be treated
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Antibiotics NOT recommended for prevention of UTI
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Catheters are usually changed every 3 months
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With UTI, it is important to change catheter every 1-2 weeks (duration of time for bacterial biofilm to form
When UTI is diagnosed, single agent therapy preferred which has little impact on normal flora.
Signs and symptoms to look for in UTI with neurogenic bladder are similar to normal bladder:
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annoying malodorous urine
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changes in the bladder management pattern including increased incontinence and residual urine
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signs of autonomic dysreflexia with increased sweating, increased spasticity, discomfort or pain over the kidney or bladder
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malaise, lethargy, sense of unease or fever
Hand washing is an important deterrent in UTI formation.
What are the consequences of ignoring the impact of rehabilitation services on infection control?
Gastrointestinal:
In Rehabilitation populations, GI infection may cause worsening of underlying symptoms (e.g., weakness in all neurologic conditions, cognitive decline in individuals with traumatic brain injury, stroke, multiple sclerosis or encephalopathy), cause new conditions related to the underlying disabling condition (e.g., Autonomic Dysreflexia with spinal cord injury, spasticity with any upper motor neuron disorder) and cause an overall increase in mortality.
Pulmonary:
The incidence of aspiration and aspiration pneumonia is elevated in rehabilitation services that do not routinely utilize SLP specialists to evaluate all individuals with acute disabling disorders that put them at risk for aspiration.
Skin:
Rehabilitation unit (patients and staff) colonization with multidrug resistant organisms may occur if skin care protocols (hand washing, local treatment, and isolation precautions) are not followed.
Genitourinary:
In Rehabilitation populations, GU infection may cause worsening of underlying symptoms (e.g., weakness in all neurologic conditions, cognitive decline in individuals with traumatic brain injury, stroke, multiple sclerosis or encephalopathy), cause new conditions related to the underlying disabling condition (e.g., Autonomic Dysreflexia with spinal cord injury, spasticity with any upper motor neuron disorder) and cause an overall increase in mortality.
Multidrug resistance is more common in individuals on rehabilitation units that routinely management of asymptomatic skin colonization or pressure ulcers with systemic antibiotics.
The incidence of aspiration and aspiration pneumonia is elevated in rehabilitation services that do not routinely utilize and follow strict dietary protocols (as recommended by SLP specialists) for all individuals with acute disabling disorders that put them at risk for aspiration.
What other information supports the research regarding rehabilitation services?
Meta-analysis, peer–reviewed and evidence based research support key conclusions.
Summary of current controversies.
Gastrointestinal:
Standard treatment of c.difficile colitis with Metronidozole is controversial in brain injury patients due to its systemic absorption and possible sedating/impairing effects. Oral Vancomycin, which has no systemic absorption, is preferred.
Use of probiotics appear to be generally safe in an outpatient setting, the situation may be different in immunocompromised, hospitalized patients who may be at a greater risk of developing probiotic sepsis. Probiotics are often used in individuals with significant GI dysmotility and need for long-term enteral feeding (e.g., individuals with significant disorders of consciousness). No studies exist addressing the issue of safety specifically.
Prophylactic antibiotics may reduce the incidence of post-insertion infection in PEG tubes.
Pulmonary:
None
Skin:
Maintaining contact precautions for individuals with multidrug resistant skin colonization is challenging in both inpatient and outpatient rehabilitation settings, where hands on therapy and community socialization are an integral aspect of care. As inpatients, most patients are put on strict contact isolation when in their room, however, are then only treated with universal precautions when in a therapy area or off the unit for community reintegration or socialization activities. Outpatients are typically only managed with universal precautions.
While the ultimate prevention strategy for pressure ulcer-related infections is healing of the ulcer, which is best accomplished following established protocols that include total non-weight-bearing on the affected skin, the challenges of balancing skin non-weight-bearing and the need for mobilization and activity for successful rehabilitation often delay full healing.
Genitourinary:
A concise definition of UTI is controversial, though criteria exist to unify clinical signs, lab work, and patient presentation to make the diagnosis.
Topical antiseptics have not been shown to prevent bacteriuria in individuals utilizing indwelling catheters, and should not be used.
Antiseptics in drainage bags and used after intermittent catheterization have not been shown to prevent bacteriuria, and should not be used.
Bladder washouts can cause increased risk of bacterial resistance and chemical cystitis, and should not be used.
Agents that acidify or alkalinize the urine have not been shown to reliably prevent UTI, and should be used only if clinical parameters support efficacy.
Emerging evidence exists to support the role of intentional colonization with recombinant bacteria (e.g., E.coli 83972) to reduce UTIs in patients with neurogenic bladders managed with indwelling catheters.
What is the impact of rehabilitation services relative to the impact of other aspects of infection control?
Gastrointestinal: Rehabilitation follows the guidelines of Infectious Disease in relation to other patient populations, though Rehab specific research has helped to clarify treatment of GI tract infections in our unique patient populations.
Pulmonary: Rehabilitation follows the guidelines of Infectious Disease in the prevention and management of pulmonary-related infection.
Skin: Rehabilitation follows the guidelines of Infectious Disease in relation to other patient populations, though Rehab specific research has helped to clarify treatment of skin infections in our unique patient populations.
Genitourinary: Rehabilitation follows the guidelines of Infectious Disease in relation to other patient populations, though Rehab specific research has helped to clarify treatment of UTIs in unique disability patient populations (e.g., those with neurogenic bladders).
Overview of important clinical trials, meta-analyses, case control studies, case series, and individual case reports related to infection control and rehabilitation services.
See Table I and Table II for a summary of relevant research regarding rehabilitation services and infection control.
Table I.
| AuthorYearCountryScoreResearch DesignTotal Sample Size | Methods | Outcome |
|---|---|---|
| Pow et al 2005Hong KongLongitudinal Comparison StudyN=43 stroke survivors compared to N=43 non-stroke community dwellers | Population: 43 elderly survivors of mild to moderate stroke about to be discharged from hospital after rehabilitation and a comparison group of 43 community-dwelling elderly people.Outcome Measures: Assessed dental caries, periodontal disease, oral hygiene, oral candidiasis, prosthetic status/need and functional disability (Barthel Index [BI]) at discharge and 6 months. | · Stroke survivors had significantly higher plaque and bleeding scores and poorer periodontal condition with more 4-5mm pockets, on hospital discharge and after six months compared with the control group (p<0.01).· · The mean BI on hospital admission was 71 and 91 on discharge. Stroke survivors with a higher BI on discharge had lower plaque scores after six months.· · The tooth condition, number of functional tooth pairs, prosthetic status, presence of oral candidiasis and oral yeast carriage were similar between stroke and comparison groups. (p=1.0). |
| Blomberg et alSwedenRandomized Controlled TrialN = 234 | Population: patients with an indication for PEGTreatment: A single 20 ml dose of the oral solution of sulfamethoxazole and trimethoprim deposited in the PEG catheter immediately after insertion. The control group received standard prophylaxis consisting of a single intravenous dose of 1.5 g cefuroxime administered before insertion of the PEG tube.Outcome Measures: Primarily, the occurrence of clinically evident wound infection within 14 days after insertion of the PEG catheter. Secondary outcomes: + bacterial culture and elevated C reactive protein and white blood cell count. | · At 7-14 days, wound infection was found in 10 (8.6%) patients in the co-trimoxazole group and 14 (11.9%) in the cefuroxime group, which corresponds to a percentage point difference of -3.3% (95% confidence interval -10.9% to 4.5%).· Analyses indicate non-inferiority of co-trimoxazole compared with cefuroxime because the upper bounds of the confidence intervals are lower than the pre-determined non-inferiority margin of 15%. Analyses of the secondary outcomes supported this finding.· |
| Allen et all. Cochrane Database Review 2, 2004 | Cochrane Infectious Diseases Group’s trials register (December 2002), the Cochrane Controlled Trials Register (The Cochrane Library Issue 4, 2002), MEDLINE (1966 to 2002), EMBASE (1988 to 2002), and reference lists from studies and reviews.Selection Criteria: Randomized controlled trials comparing a specified probiotic agent with placebo or no probiotic in people with acute diarrhea that is proven or presumed to be caused by an infectious agent.Data Analysis: Two reviewers independently assessed trial methodological quality and extracted data.Outcome Measures: To assess the effects of probiotics in proven or presumed infectious diarrhea. Measured incidence, rotavirus diarrhea, and national mortality rates. | · Probiotics reduced the risk of diarrhea at 3 days (relative risk 0.66, 95% confidence interval 0.55 to 0.77, random effects model; 15 studies) and the mean duration of diarrhea by 30.48 hours (95% confidence interval 18.51 to 42.46 hours, random effects model, 12 studies).Probiotics appear to be a useful adjunct to rehydration therapy in treating acute, infectious diarrhea in adults and children. |
Table II.
| Author YearCountryScoreResearch DesignTotal Sample Size | Methods | Outcome |
|---|---|---|
| Darouiche et al. 1997 USAPEDro=7RCT (study 1)Pre-post (study 2)Study 1 N=45/40Study 2 N=12 | Population: SCI with symptomatic polymicrobial UTI: Age = 23-84 yrs; Gender: males.Treatment: Limited vs. full microbiological investigation for management of symptomatic polymicrobial UTI (limited = cultures for specific organisms not used to guide antibiotic selection).Outcome Measures: Clinical improvement following symptomatic UTI (criteria defined as presence of bacteria + one symptom) by 4 days after treatment with antibiotic, time to start antibiotic, cost of entire therapy and lab tests. |
No difference in therapy response between full vs. limited approach (95% vs 85%, p=0.4); Limited approach antibiotic initiation earlier at 1.2+/-1.4 days vs. 3.3+/-2.5 days for full approach (p=.01); Higher proportion of people in limited group required no change in initial antibiotic than with full approach 85% vs 33% (p=.006); Recurrence at 1 month due to at least 1 of the originally infecting species was similar for both groups (p=1.0); Costs for limited investigation-directed therapy less @ $157+/- $174 vs. $252 +/- $237 for full approach indicative of a trend but not significantly different (p=.18) |
| Horton et al. 1998USAPEDro=6RCTN=40 | Population: SCI, inpatients.Treatment: Urine sample was processed within 4 hrs of sampling (“fresh”) vs. 24 (“refrigerated” ) hours of refrigeration.Outcome Measures: Cultures, colony counts, urinalysis. |
No significant difference between fresh and refrigerated samples in: WBC (p=0.724), # bacteria (p = 0.440) leukocytes (p = 0.782), colony counts of E. fecalis & Pseudomonas (p =0.317), E. coli, Citrobacter, Streptococcus, Yeast, or Acinetobacter (p=1.0). Significant difference between fresh & refrigerated samples with colony counts <50 k: “mixed” organisms (p = 0.010) Staph aureus trend only (p=0.066) No cultures/colony count changes in up to 24h refrigeration to alter treatment or clinically significant urinalysis/culture results. |
| Shah et al. 2005USAPEDro=4Prospective controlled trialN=85 | Population: SCI in patients with indwelling / suprapubic catheter and suspected of having a UTI; Control group (n=41): mean age = 55.6yrs; Treatment group (n=44): mean age = 64.1yrs.Treatment: Patients were admitted to two spinal cord units: 1) continued the routine practice of examining urine samples without replacing the catheter (Control group) ; vs. 2) nurses replaced catheter before obtaining urine samples (Treatment group) for urinary analysis.Outcome Measures: Prevalence of organisms, types of organisms, laboratory costs. |
More clinically significant organisms (≥105 cfu/mL) were found in those whose catheter was not changed vs. changed (89/41 patients vs. 60/44 patients, p=0.01). Fewer non-clinically significant organisms (<105 cfu/mL) were found in those whose catheter was not changed vs. changed (4/41 patients vs 19/44 patients, p=0.01). Changed catheter group had significantly less multidrug resistant organisms than the control group (p<0.001). The changed vs. unchanged catheter approach resulted in a total cost reduction of $15.64 per patient. |
| Tantisiriwat et al. 2007ThailandDowns and Black score=16Case seriesN=76 | Population: SCI hospitalized at Rehabilitation Center (Thai Red Cross Society); Mean age = 44.7 yrs ; Gender: males = 50, females = 26; Type of neurogenic bladder: detrusor overactivity = 39, detrusor underactivity = 9.Treatment: Retrospectively chart review to assess UTI prevalence, causative bacteria and susceptibility patterns.Outcome Measures: Causative bacteria, susceptibility to antibiotic, prevalence of UTI. |
Prevalence of UTI was higher in patients with neurogenic detrusor overactivity (97.14%) than underactivity (66.67%). Of urine culture performed in 41/68 episodes of UTI, 39 positive cultures identified with E. coli (74.4%), K. pneumonia (12.8%), Enterococcus faecalis (5%) and Proteus mirabilis (5%) most common. E. coli was most susceptible to amikacin (96.1%), ceftazidime (88.9%), and cetriaxone (75%). K. pneumonia was most susceptible to ceftazidime (80.0%), cetriaxone (80.0%), amikacin (60.0%) and cotrimoxazole (60%). |
| Hoffman et al. 2004USADowns & Black score=16CohortN=56 | Population: SCI > 6months post-injury who reported recurrent UTIs: Mean age = 38.86 yrs; Gender: males = 42, females = 14; Level of injury: tetraplegia = 34.Treatment: Comparing dipstick results for Nitrites or leukocyte esterase (LE) to urine culture results.Outcome Measures: Urine samples (nitrate, LE and culture) and self-report of symptoms, UTI presence and treatment collected monthly over 3 years and then only for 10 months over last 2 years. Sensitivity, specificity, under-treatment, overtreatment were assessed. |
In predicting significant bacteriuria, when either Nitrates or LE separately or both were positive there was a low sensitivity (0.63) and over-treatment rate (0.04) with a high specificity (0.89) and under-treatment rate (0.96). In predicting NIDRR-based UTI, when either Nitrates or LE separately or both were positive there was a low sensitivity (0.64) but also a low specificity (0.52) resulting in a higher over-treatment (0.66) and lower under-treatment rate (0.22) than seen with bacteriuria prediction. Overall results suggest using dipstick testing as a treatment guide could result in over-treatment rates of 70% and low rates of under-treatment. |
| Faarvang et al. 2000DenmarkDowns and Black score=7Pre-PostN=143 | Population: Those with spinal cord lesion admitted to inpatient SCI program.Treatment: 256 morning urine samples were collected from patients using a standardized ‘clean’ technique. Analysis was conducted with chemical dipstick and microscopy within 3 hours.Outcome Measures: Prevalence of bacteria compared with nitrite/leukocyte dipstick tests (positive and negative predictive values), types of bacteria. |
The authors suggested that results comparing +ive and -ive predictive values indicated that the dipstick and microscopy tests are both equally valuable. True –ive predictive value ~0.7 and true +ive predictive value of ~0.9. 128 out of 256 urine samples contained significant bacteriuria. Only 87 contained just one microorganism. |
Note: UTI=Urinary Tract Infection
Controversies in detail.
Gastrointestinal: C. difficile colitis has not been consistently shown to be prevented by the use of probiotic co-treatment in a number of studies [Pillai and Nelson 2008; McFarland 2006]. In one large study, boulardil along with vancomycin and metronidazole was associated with a significant decrease in colitis recurrence [McFarland 1994].
Infectious diarrhea in both adults and children may be shortened by the use of probiotics. In this Cochrane review, 23 studies including almost 2000 participants (352 of which were adults), it was concluded that probiotics reduced the risk of persistent diarrhea compared with placebo or no probiotics at 3 days with a RR of 0.66 (95% CI 0.55–0.77). [Allen et al. 2004].
Pulmonary: None
Skin: None
Genitourinary: The definition of UTI varies due to the range of signs and symptoms that are used to define UTI related to individuals with neurogenic bladder from upper or lower motor neuron disorders (e.g., spinal cord injury, brain injury, multiple sclerosis, stroke, neuropathy, Parkinson’s disease) do not have the classic symptoms seen in able-bodied individuals.
Controversy exists also regarding treatment of asymptomatic bacteriuria. It is recommended that the first episode of UTI should be treated with antibiotics. Treatment for subsequent episodes of UTI is more controversial, as the risk of treating colonization can lead to multi-drug resistant organisms and therefore must be individualized.
What national and international guidelines exist related to rehabilitation services and infection control?
Gastrointestinal:
Royal College of Physicians National Clinical Guidelines
American Spinal Cord Injury Clinical Guidelines
The National Spinal Cord Injury Association Clinical Guidelines
US Department of Health and Human Services, National Guideline Clearinghouse
Pulmonary:
Standard contact and universal precaution guidelines
Skin:
Standard contact and universal precaution guidelines
Genitourinary:
The prevention and management of urinary tract infection among people with spinal cord injuries: National Institute on Disability and Rehabilitation Consensus Statement: January 27–29, 1992. J Am Paraplegia Soc. 1992; 15(3):194–204.
Bladder Management for adults with Spinal Cord Injury – A Clinical Practice Guideline for Health-Care Providers (Paralyzed Veterans of America – 2010).
What other consensus group statements exist and what do key leaders advise?
Genitourinary: The treatment of neurogenic bladder-associated UTI has not been well studied in different treatment settings (inpatient, skilled nursing facility, nursing home); however, at present it is advised that the treatment of UTI be the same in all settings. The setting for the infection (neurogenic bladder) appears more relevant than the physical setting in which the infection occurred. Since patients with neurogenic bladders typically will have multiple UTI’s over the course of their lives, it is advisable to use the narrowest spectrum oral antibiotics, with confirmation of appropriate treatment with a urine culture and sensitivity.
References
Gastrointestinal:
Allen, S.J., Okoko, B., Martinez, E., Gregorio, G. and Dans, L.F. Probiotics for treating infectious diarrhoea. Cochrane Database Syst Rev 2: CD003048, 2004.
(Valuable review of probiotic use in different GI illnesses.)
Consortium for spinal cord medicine: neurogenic bowel management in adults with spinal cord injury. Washington, DC: Paralyzed Veterans of America; 1998.
(Valuable guide to the overall management of neurogenic bowel.)
David W. Pruitt, MD, Tobias Tsai, MD. Common Medical Comorbidities Associated with Cerebral Palsy, Physical Medicine and Rehabilitation Clinics of North America – Volume 20, Issue 3 (August 2009)
(Pediatric rehabilitation specific guide.)
Greenhill W. Dental care for children with disabilities. In: Rudolph CD, Rudolph AM, Hostetter MK, et al, editors. Rudolph’s pediatrics. New York: McGraw-Hill; 2003. p. 541–2
(Pediatric rehabilitation specific guide.)
Hockstein NG, Samadi DS, Gendron K, et al. Sialorrhea: a management challenge. Am Fam Physician 2004;69(11):2628–34.
(Sialorrhea management specific guide.)
Lynch AC, Antony A, Dobbs BR, et al. Bowel dysfunction following spinal cord injury. Spinal Cord 2001;39:193–203.
(Valuable guide to the overall management of neurogenic bowel.)
Mahadeva S, Sam IC, Khoo BL, Khoo PS, Goh KL. Antibiotic prophylaxis tailored to local organisms reduces percutaneous gastrostomy site infection. Int J Clin Pract. 2009 May;63(5):760-5. Epub 2009 Feb 16.
(Management guide for GI infection.)
McFarland, L.V., Surawicz, C.M., Greenberg, R.N., Fekety, R., Elmer, G.W., Moyer, K.A. et al. A randomized placebo-controlled trial of Saccharomyces boulardii in combination with standard antibiotics for Clostridium difficile disease. JAMA 1994 271: 1913–1918.
(Review of probiotic effectiveness.)
Mylotte JM, Graham R, Kahler L, Young L, Goodnough S: Epidemiology of Nosocomial Infection and Resistant Organisms in Patients Admitted for the First Time to an Acute Rehabilitation Unit. Clin Infect Dis. (2000) 30 (3): 425-432.
(Review of nosocomial infection in rehabilitation units.)
Nicolle LE, Buffet L, Alfieri N, Tate R: Nosocomial infections on a rehabilitation unit in an acute care hospital. Infection Control and Hospital Epidemiology 1988;9(12):553-558
(Review of nosocomial infection in rehabilitation units.)
Niessen LC, Fedele DJ. Aging successfully: oral health for the prime of life. Compend Contin Educ Dent. 2002 Oct;23(10 Suppl):4-11.
Petrof EO. Probiotics and Gastrointestinal Disease: Clinical Evidence and Basic Science. Anti-inflamm Antiallergy Agents Med Chem. 2009 Sep 1;8(3):260-269.
Pow EH, Leung KC, Wong MC, Li LS, McMillanAS. A longitudinal study of the oral health condition of elderly stroke survivors on hospital discharge into the community. Int Dent J. 2005 Oct;55(5):319-24.
Singh G, Triadafilopoulos G. Gastroesophageal reflux disease in patients with spinal cord injury. J Spinal Cord Med. 2000 Spring;23(1):23-7.
(Review of management options.)
Valles M, Vidal J, Clave P, et al. Bowel dysfunction in patients with motor complete spinal cord injury: clinical, neurological, and pathophysiological associations. Am J Gastroenterol 006;101:2290–9.
Pulmonary:
Addington WR, Stephens RE, Gilliland KA: Assessing the laryngeal cough reflex and the risk of developing pneumonia after stroke: An interhospital comparison stroke 1999;30:1203-1207.
(Review of risk factors for aspiration.)
Chen D, Apple DF, Hudson LM, Bode R: Medical complications during acute rehabilitation following spinal cord injury—current experience of the model systems. Arch Phys Med Rehabil 1999;80(11):1397-1401.
(Review of pneumonia issues in Spinal Cord Injury.)
Cogen R, Weinryb J: Aspiration pneumonia in nursing home patients fed via gastrostomy tubes. Am J Gastro 1989;84(12):1509-12.
(Review of pneumonia issues in nursing home patients.)
Langmore SE, Terpenning MS, Schork A, Chen Y, etal: Predictors of Aspiration Pneumonia: How Important Is Dysphagia? Dysphagia 1998;13:69-81.
(Review of risk factors for aspiration.)
Marciniak C, Korutz A, Lin E, Roth E, Welty L, Lovell L: Examination of selected clinical factors and medication use as risk factors for pneumonia during stroke rehabilitation: a case-control study. Am J Phys Med Rehabil 2009;88(1):30-38.
(Review of pneumonia issues in stroke.)
Marik PE: Aspiration pneumonitis and aspiration pneumonia. N Engl J Med 2001;344:665-671.
(Review of risk factors for aspiration.)
Marik PE, Kaplan D: Aspiration Pneumonia and Dysphagia in the Elderly. Chest 2003;124(1):328-336.
(Review of pneumonia issues in older adults.)
Masiero S, Pierobon R, Previato C, Gomiero E: Pneumonia in stroke patients with oropharyngeal dysphagia: a six-month follow-up study. Neurol Sci 2008;29(3):139-145.
(Review of pneumonia issues in stroke.)
Mylotte JM, Graham R, Kahler L, Young L, Goodnough S: Epidemiology of Nosocomial Infection and Resistant Organisms in Patients Admitted for the First Time to an Acute Rehabilitation Unit. Clin Infect Dis. (2000) 30 (3): 425-432.
(Review of nosocomial infection in rehabilitation units.)
Nicolle LE, Buffet L, Alfieri N, Tate R: Nosocomial infections on a rehabilitation unit in an acute care hospital. Infection Control and Hospital Epidemiology 1988;9(12):553-558
(Review of nosocomial infection in rehabilitation units.)
Teasell RW, Foley N, Doherty T, Finestone H: Clinical characteristics of patients with brainstem strokes admitted to a rehabilitation unit. Arch Phys Med Rehabil 2002;83(7):1013-1016.
(Review of pneumonia issues in stroke.)
Teasell RW, Foley N, Fisher J, Finestone H: The Incidence, Management, and Complications of Dysphagia in Patients with Medullary Strokes Admitted to a Rehabilitation Unit. Dysphagia 2002;17(2):115-120.
(Review of pneumonia issues in stroke.)
Teasell RW, McRae M, Heitzner J, Bhardwaj A, Finestone H. Frequency of videofluoroscopic modified barium swallow studies and pneumonia in stroke rehabilitation patients: A comparative study. Arch Phys Med Rehabil 1999;80(3):294-298.
(Review of pneumonia and dysphagia issues in stroke.)
Skin:
Cutting KF. Wound healing, bacteria and topical therapies. EWMA Journal. 2003;3(1):17–19.
(Standardized management for skin breakdown and wounds.)
Cutting KF, Harding KG. Criteria for identifying wound infection. J Wound Care. 1994;3(4):198–201.
(Assessment tool for skin infection.)
Cutting KF, White RJ: Criteria for identifying wound infection – revisited: Br J Comm Nurs 2004;9(3 Suppl);S6–S16.
(Assessment tool for skin infection.)
Edwards R, Harding KG. Bacteria and wound healing. Current Opinion Infect Dis. 2004;17:2:91–96.
(Review of the role of infection in skin healing.)
Heggers JP. Defining infection in chronic wounds: does it matter? J Wound Care. 1998;7(8):389–392.
(Review of the role of infection in skin healing.)
Mylotte JM, Graham R, Kahler L, Young L, Goodnough S: Epidemiology of Nosocomial Infection and Resistant Organisms in Patients Admitted for the First Time to an Acute Rehabilitation Unit. Clin Infect Dis. (2000) 30 (3): 425-432.
(Review of nosocomial infection in rehabilitation units.)
Nicolle LE, Buffet L, Alfieri N, Tate R: Nosocomial infections on a rehabilitation unit in an acute care hospital. Infection Control and Hospital Epidemiology 1988;9(12):553-558
(Review of nosocomial infection in rehabilitation units.)
Pham B, Stern A, Chen W, Sander B, etal: Preventing Pressure Ulcers in Long-term Care. A Cost-effectiveness Analysis. Arch Intern Med. 2011;171(20):1839-1847.
(Prevention strategies for pressure ulcers.)
Reddy M, GillSS, Rochon PA: Preventing Pressure Ulcers: A Systematic Review. JAMA. 2006;296(8):974-984.
(Review of assessment, prevention and management of pressure ulcers.)
Schultz G S, Sibbald R G, Falanga V, et al. Wound bed preparation: a systematic approach to management. Wound Rep Regen. 2003;11(2 suppl):S1–S28.
Stephens, P, Wall IB, Wilson MJ. Cutaneous biology: anaerobic cocci populating the deep tissues of chronic wounds impair cellular wound healing responses in vitro. Br J Dermatol. 2003;148:456–466.
White RJ. The wound infection continuum. In: White RJ, ed. Trends in Wound Care. Vol 2. Dinton, Salisbury, UK: Quay Books;2003.
Wall IB, Davies CE, Hill KE et al. Potential role of anaerobic cocci in impaired human wound healing. Wound Rep Regen. 2002;10(6):346–353.
Wilson AP, Weavill C, Burridge J, Kelsey MC. The use of the wound scoring method ‘ASEPSIS’ in postoperative wound surveillance. J Hosp Infect. 1990;16(4):297–309
(Assessment tool for skin infection.)
Genitourinary:
Biering-Sorensen F, Bagi P, Hoiby N. Urinary Tract Infections in Patients with Spinal Cord Lesions. Drugs 2001; 61 (9): 1275-1287.
(Overview of UTI in SCI.)
Darouiche RO, Thornby JI, Stewart-Cerra C, Donovan WH, Hull RA. Bacterial Interference for Prevention of Urinary Tract Infection: A Prospective, Randomized, Placebo-Controlled, Double-Blind Pilot Trial. Clinical Infectious Diseases 2005;41:1531–4.
(Use of modified bacteria for UTI.)
Darouiche RO, Priebe M, Clarridge JE. Limited vs. full microbiological investigation for the management of symptomatic polymicrobial urinary tract infection in adult spinal cord injured patients. Spinal Cord (1997) 35, 534-539.
(Overview of UTI in SCI.)
Garcia Leoni ME, Esclarin De Ruz A. Management of urinary tract infection in patients with spinal cord injuries. Clin Microbiol Infect 2003; 9: 780-785.
(Overview of UTI in SCI.)
Galloway A. Prevention of urinary tract infection in patients with spinal cord injury-a microbiological review. Spinal Cord (1997) 35, 198-204.
(Overview of UTI in SCI.)
Mylotte JM, Graham R, Kahler L, Young L, Goodnough S: Epidemiology of Nosocomial Infection and Resistant Organisms in Patients Admitted for the First Time to an Acute Rehabilitation Unit. Clin Infect Dis. (2000) 30 (3): 425-432.
(Review of nosocomial infection in rehabilitation units.)
Nicolle LE, Buffet L, Alfieri N, Tate R: Nosocomial infections on a rehabilitation unit in an acute care hospital. Infection Control and Hospital Epidemiology 1988;9(12):553-558
(Review of nosocomial infection in rehabilitation units.)
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