Prevention of Urinary Tract Infection (UTI) in Persons With Spinal Cord Injury (SCI)
Condition: Urinary Tract Infections
MeSH terms: Infections; Urinary Tract Infections; Spinal Cord Injuries
Study type: Interventional

Summary: 
      Urinary tract infection (UTI) is the most common infection in patients with spinal cord
      injury (SCI) and is linked to major undesired results or complications including death. The
      bladder of SCI patients, especially those with indwelling catheters, is usually colonized by
      bacteria, some of which do and others which do not cause symptoms of UTI. Bacteria that do
      not cause symptoms are often called benign colonizers and are often left untreated because
      they may provide some protection against infection with more harmful bacteria. This idea of
      using benign bacteria to prevent infections with symptoms is called bacterial interference. A
      prototype strain, Escherichia coli 83972, was shown to begin and continue for extended
      periods of time non symptom causing colonization of the human bladder and to hold back
      symptom causing infections of the neurogenic bladder. Data from pilot studies at two medical
      centers indicated that bacterial interference might be a useful therapy for reducing the rate
      or frequency of UTI in SCI patients. Because almost all SCI patients have a UTI at some time,
      and also the large costs of treating this infection, studying the impact of bladder
      colonization with E. coli 83972 on the rate of symptom causing UTI has an amazing potential
      for improving the quality of life of SCI patients and decreasing the cost of health care.
      Like with other preventive plans such as vaccination, for instance, it is important to
      explore the effectiveness of this new preventive approach. The project is a prospective,
      randomized, double blind, multi-center study that deals with specific pieces of bacterial
      interference in SCI patients.

      HYPOTHESES: Placing non symptom causing bacteria (E. coli 83972) into SCI patients' bladders
      reduces the rate of symptom causing UTI.

      A. SPECIFIC AIM: Determine how bladder colonization with E. coli 83972 or similar bacteria
      affects the rate of symptom causing urinary tract infections in a large group of SCI and
      Spina Bifida patients by conducting a prospective, randomized, placebo-controlled,
      multi-center clinical trial.
    

Detailed description: 
      This clinical trial will be take place in a total of 7 medical centers that care for Spinal
      cord injury (SCI) and Spina Bifida patients. A total of 160 patients will be allowed to take
      part in the study.

      The study coordinator will interview patients by telephone and in person who express an
      interest in taking part in the study. After an informed consent and HIPAA documents are
      reviewed and all of the patients questions are answered, then they will be asked to sign
      these two forms. Then a code number will be assigned to each patient and used along with
      their initials to identify them for the remainder of the study. All study participants will
      have a complete history and physical examination including ASIA classification, serum
      creatinine and a urine culture immediately upon entry into the study. One of the following 3
      diagnostic tests must be completed within the 3 months before the study: KUB, IVP, or
      non-contrast abdominal CT scan. A voiding cystourethrogram with fluoroscopy (VCUG) alone or
      as part of a video urodynamics evaluation must be completed within 1 year before the study.

      Randomization and sample size: Enrolled subjects will be randomized in a 3:1 ratio to receive
      bladder inoculation either with E. coli 83972 (experimental group) or with placebo (control
      group). This randomization ratio was selected because around 1/3 of colonized subjects are
      expected to remain colonized for 12 months.

      Bladder inoculation: At study entry, a urine culture and sensitivity test will be completed
      using a fresh mid stream (after the urine is flowing) urine sample removed via a catheter
      into the bladder. Subjects will stop all actions to prevent or slow urinary tract infection
      (UTI) for at least two weeks upon entry into the study. Each subject will be treated with
      correct antibiotics for 7 - 10 days and any existing urinary catheter changed three days
      after starting antibiotic treatment. Forty-eight to 72 hours or (80 to 90 hours for
      fluoroquinolone antibiotics) after completion of antibiotics, the urine will be re-cultured
      and the lower urinary tract inoculated with E. coli 83972 or placebo.

      Most subjects, even those with external condom catheters, have worn a Foley catheter at some
      time, and would be expected to know the catheter size that best fits them. Subjects will be
      inoculated on three consecutive days. Inoculation will consist of putting into the bladder
      via a sterile catheter 10 ml of normal saline alone or containing E. coli 83972. Subjects who
      are incontinent at low bladder volumes will be monitored with a Foley catheter balloon
      blocking the bladder neck or diversion stoma for 30 minutes after inoculation. After 30 min.,
      the clamp will be released and the bladder allowed to drain for an additional 30 min. The
      bladder inoculation will be repeated a second time unless an unexpected adverse event
      (complication) is encountered. After the catheter is un-clamped for the second time, the
      subject will be observed for 30 min. before discharge.

      If the 48-hour culture from the sample taken just prior to inoculation is positive for
      bacteria, and E. coli 83972 colonization was not present in the sample, another antibiotic
      treatment/inoculation cycle will be attempted. The timing of the second attempt will be
      decided by the CORE director and the local principal investigator. At the correct time,
      another 7-10 day course of antibiotic therapy will be repeated. Three days after starting
      antibiotics, any existing urinary catheter will be changed. Forty-eight to 72 hours or (80 to
      90 hours for fluoroquinolone antibiotics) after completion of this course of antibiotics, the
      urine will be re-cultured and then the bladder re-inoculated. If the 48 hour culture taken
      just prior to this inoculation is again positive for any bacteria other than E. coli 83972,
      and E. coli 83972 colonization is not present as a result of the second inoculation cycle, a
      third cycle of antibiotic treatment/inoculation will be attempted. The timing of the 3rd
      attempt will be decided by the CORE director and the local principal investigator. No further
      colonization attempts will be made in study participants who are not colonized after three
      sets of attempts. We will continue to monitor subjects in this group for the remaining months
      of the study, but for analysis purposes, they will be treated as "never colonized".

      All inoculated subjects who remain without symptoms will return to their study center to have
      a urine sample collected and a brief medical interview one week after inoculation and monthly
      for the remaining 12 months. The CORE director can allow a subject who lives far from any
      center to mail their monthly urine samples directly to the CORE. All needed supplies such as:
      urine specimen containers, proper shipping containers, labels, pre-paid postage, etc.… will
      be provided at no cost to the subject. The subject's study site will contact them to conduct
      the brief medical interview.

      At the end of 12 months, subjects will receive an antibiotic to clear E. coli 83972 from
      their bladder and the study will be finished. If a subject experienced an adverse event
      (something unexpected) during the study, they will be followed by the research staff until
      the event has gone back to normal or resolved.

      Growth of E. coli 83972 in the urine will indicate bladder colonization. Subjects will be
      considered colonized as long as E. coli 83972 is present and even if there are other bacteria
      in the urine. Subjects who develop symptoms of a UTI will be treated with proper antibiotics
      guided by susceptibility patterns for the bacteria(s) grown from urine cultures. Urine
      cultures collected prior to starting treatment will be tested for E. coli 83972. It is
      important to note that although the method of bladder inoculation carries some risk of
      causing symptoms of a UTI, that risk is rather small and will be shared by all subjects.

      There exists a risk that clamping of the bladder for 30 minutes may result in autonomic
      dysreflexia in some patients, especially those who dump urine. All subjects will be asked
      about a history of autonomic dysreflexia or any unexpected response to bladder filling prior
      to inoculation. Before beginning inoculation, urodynamics data will be reviewed. All subjects
      with a lesion level above T7 will have their blood pressure (BP) monitored every 3 - 5
      minutes while the catheter is clamped. If the subject reports any symptoms associated with
      autonomic dysreflexia; e.g., headache, sweating, flushing and so forth, or if the BP monitor
      records a systolic or diastolic BP 20 mm Hg above baseline or in any case, if the systolic BP
      exceeds 150 or the diastolic BP exceeds 100 mm Hg, the catheter will be un-clamped.
      Monitoring will continue until the subject is without symptoms with their baseline BP's.
      Interventions, including elevating the head of the bed, lowering the legs, as well as
      pharmacologic measures (nitropaste, nifedipine, etc.) will be used if needed. The use of
      pharmacologic measures and any other measures will follow the Clinical Procedures Guidelines
      for acute management of autonomic dysreflexia published by the Paralyzed Veterans of America.
    

Intervention name(s): bacterial interference
Intervention type(s): Procedure
Allocation: Randomized
Intervention model: Parallel Assignment
Intervention model description: Active intervention that includes bacterial interference using E. coli 83972 is compared with a placebo intervention.
Masking: Triple (Participant, Care Provider, Investigator)
Primary purpose: Prevention
Keywords: UTI; SCI; E coli; Prevention