Commentary to “Intermittent Catheterization with a Hydrophilic-coated Catheter Delays the Occurrence of Urinary Tract Infection in Patients with Acute Spinal Cord Injury: A Prospective, Randomized, Parallel, Multicenter Trial”

Abstract

Hydrophilic catheters for intermittent catheterization have been available for almost 2 decades, nd the literature about them is primarily limited to small clinical trials. The researchers in this tudy examined the occurrence of urinary tract infections (UTI) in patients with spinal cord njury (SCI) within the first months after injury, who were randomized to treatment with either terile, single-use, uncoated polyvinyl chloride (PVC) catheters or sterile, single-use, hydrophilic atheters. The researchers should be commended for conducting this large, randomized study to xamine the comparative efficacy of these catheters. Several issues are worth noting. First, the selection of patients who have new SCI to test the ntervention is problematic. As the researchers themselves state, the bladder management of hese patients often changes during the first several months after injury, which (among other actors) contributes to the very high dropout rate in this study, and the attrition casts doubt on he conclusions. Second, one of the main outcomes, time to first symptomatic UTI, is clinically rrelevant. The occurrence of a first UTI does not predict the future recurrence of infection, or any esultant morbidity. Third, another primary outcome, total number of UTIs in the entire study eriod (not just the institutional or community period in isolation), no difference in UTI could e detected between the 2 groups of patients with respect to the catheter types used. In my pinion, this is the primary outcome of the study, and the data do not demonstrate an advantage f the hydrophilic over the PVC catheter. Although not the primary emphasis of the study, the researchers bring up an excellent point, hat of the emergence of antibiotic resistant organisms in the SCI population. It is tempting to ntuit the use of sterile, hydrophilic catheters as more likely to decrease the risk of symptomatic TIs in persons with SCI and thus decrease antibiotic use and the development of resistance. owever, it is important to recall the principles of bladder management that Lapides et al [1] advocated in the revolutionary article on clean intermittent catheterization, published nearly 40 years ago: Efficient, regular bladder emptying, not the maintenance of intravesical sterility, is the key to the prevention of urinary complications (including UTI) due to neurogenic bladder. If we providers recommend that our patients use hydrophilic catheters, which are all sterile and for single use, then invariably our patients will think that their bladder needs to be sterile and manipulated only with sterile catheters. When bacteriuria is identified, whether the patients are truly symptomatic or not, the patients will insist on antibiotic treatment, typically from community providers who are not familiar with neurogenic bladder management. In my practice, this mentality is the biggest contributor to antibiotic overuse, with the subsequent development of antibiotic resistance. I counsel my patients with SCI to the principles of bladder management of Lapides et al, and continue to advocate reusing catheters for clean, intermittent catheterization.