Original research| Volume 99, ISSUE 2, P219-225, February 2018

Routine Urine Testing at the Spinal Cord Injury Annual Evaluation Leads to Unnecessary Antibiotic Use: A Pilot Study and Future Directions

Published:October 26, 2017DOI:



      To measure the prevalence of asymptomatic bacteriuria (ASB) in persons with spinal cord injury (SCI) at the time of their annual examination and to examine the effect on urine testing during the annual examination on subsequent antibiotic use.


      Retrospective cohort study.


      A major SCI center.


      Veterans (N=393) with SCI seen for an outpatient annual evaluation in 2012 or 2013.


      Not applicable.

      Main Outcome Measures

      Antibiotic use for bacteriuria within 7 days of the annual evaluation encounter.


      There were 327 clinic visits that met inclusion criteria; of these 327 veterans, 249 had a urine culture performed. A total of 171 urine cultures (69%) were positive for bacteria, of which 22 (13%) represented urinary tract infection (UTI) cases and 149 (87%) were ASB cases. More than a third of the ASB cases (n=53 [36%]) were treated with antibiotics. None of the 78 visits with negative urine cultures received antibiotics to treat the UTI; thus, a positive urine culture alone was associated with antibiotic use (P<.01). Factors predicting antibiotic use were higher age, nitrite presence on urinalysis, and urease-producing organism on culture media. When comparing bladder management strategies, indwelling catheterization was found to be associated with higher levels of pyuria and hematuria than did spontaneous voiding or intermittent catheterization (P<.01).


      Two-thirds of the urine cultures of persons with SCI presenting for their annual examination were positive. Most of the positive cultures represented ASB cases, and more than a third of these were treated with antibiotics. A better understanding of the mandate for urine testing at the annual examination and the outcomes of this practice is an important first step in developing antibiotic stewardship for UTI in persons with SCI.


      List of abbreviations:

      AIS (American Spinal Injury Association Impairment Scale), ASB (asymptomatic bacteriuria), EMR (electronic medical record), IDSA (Infectious Diseases Society of America), SCI (spinal cord injury), UTI (urinary tract infection), VHA (Veterans Health Administration)
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Archives of Physical Medicine and Rehabilitation
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Skelton F.
        • Hoffman J.M.
        • Reyes M.
        • Burns S.P.
        Examining health-care utilization in the first year following spinal cord injury.
        J Spinal Cord Med. 2015; 38: 690-695
        • Hooton T.M.
        • Bradley S.F.
        • Cardenas D.D.
        • et al.
        Diagnosis, prevention, and treatment of catheter-associated urinary tract infection in adults: 2009 International Clinical Practice Guidelines from the Infectious Diseases Society of America.
        Clin Infect Dis. 2010; 50: 625-663
      1. NSCISC National Spinal Cord Injury Statistical Center, The University of Alabama at Birmingham. 2012 Annual Statistical Report – Public Version. Available at: Accessed January 8, 2018.

        • Rabadi M.H.
        • Mayanna S.K.
        • Vincent A.S.
        Predictors of mortality in veterans with traumatic spinal cord injury.
        Spinal Cord. 2013; 51: 784-788
        • Nicolle L.E.
        • Bradley S.
        • Colgan R.
        • et al.
        Infectious Diseases Society of America guidelines for the diagnosis and treatment of asymptomatic bacteriuria in adults.
        Clin Infect Dis. 2005; 40: 643-654
        • Mohler J.L.
        • Cowen D.L.
        • Flanigan R.C.
        Suppression and treatment of urinary tract infection in patients with an intermittently catheterized neurogenic bladder.
        J Urol. 1987; 138: 336-340
        • Naik A.D.
        • Skelton F.
        • Amspoker A.B.
        • Glasgow R.A.
        • Trautner B.W.
        A fast and frugal algorithm to strengthen diagnosis and treatment decisions for catheter-associated bacteriuria.
        PLoS One. 2017; 12: e0174415
        • Trautner B.W.
        • Bhimani R.D.
        • Amspoker A.B.
        • et al.
        Development and validation of an algorithm to recalibrate mental models and reduce diagnostic errors associated with catheter-associated bacteriuria.
        BMC Med Inform Decis Mak. 2013; 13: 48
        • Trautner B.W.
        • Petersen N.J.
        • Hysong S.J.
        • Horwitz D.
        • Kelly P.A.
        • Naik A.D.
        Overtreatment of asymptomatic bacteriuria: identifying provider barriers to evidence-based care.
        Am J Infect Control. 2014; 42: 653-658
        • Fitzpatrick M.A.
        • Suda K.J.
        • Safdar N.
        • et al.
        Unique risks and clinical outcomes associated with extended-spectrum β-lactamase enterobacteriaceae in veterans with spinal cord injury or disorder: a case-case-control study.
        Infect Control Hosp Epidemiol. 2016; 37: 768-776
        • Fitzpatrick M.A.
        • Suda K.J.
        • Safdar N.
        • et al.
        Changes in bacterial epidemiology and antibiotic resistance among veterans with spinal cord injury/disorder over the past 9 years.
        J Spinal Cord Med. 2017; : 1-9
        • Suda K.J.
        • Patel U.C.
        • Sabzwari R.
        • et al.
        Bacterial susceptibility patterns in patients with spinal cord injury and disorder (SCI/D): an opportunity for customized stewardship tools.
        Spinal Cord. 2016; 54: 1001-1009
        • U.S. Preventive Services Task Force
        Screening for asymptomatic bacteriuria in adults: reaffirmation recommendation statement.
        Am Fam Physician. 2010; 81: 505
        • U.S. Department of Veterans Affairs
        VHA handbook 1176.01: spinal cord injury and disorders (SCI/D) system of care.
        (Available at:) (Accessed January 8, 2018)
        • Hung E.W.
        • Darouiche R.O.
        • Trautner B.W.
        Proteus bacteriuria is associated with significant morbidity in spinal cord injury.
        Spinal Cord. 2007; 45: 616-620
        • Waites K.B.
        • Canupp K.C.
        • DeVivo M.J.
        Eradication of urinary tract infection following spinal cord injury.
        Paraplegia. 1993; 31: 645-652
        • Lewis R.I.
        • Carrion H.M.
        • Lockhart J.L.
        • Politano V.A.
        Significance of asymptomatic bacteriuria in neurogenic bladder disease.
        Urology. 1984; 23: 343-347
        • Maynard F.M.
        • Diokno A.C.
        Urinary infection and complications during clean intermittent catheterization following spinal cord injury.
        J Urol. 1984; 132: 943-946
        • Centers for Disease Control and Prevention
        Vital signs. Making health care safer: stop spread of antibiotic resistance.
        Centers for Disease Control and Prevention, Atlanta2015
        • The White House Office Washington
        National action plan for combating antibiotic-resistant bacteria.
        (Available at:) (Accessed December 8, 2016)
      2. High Level Meeting on Antimicrobial Resistance. Available at: Accessed January 8, 2018.