Drug Resistant UTI's in Spinal Cord Injuries

A spinal cord injury (SCI) occurs when the spinal cord—the nerve highway between the brain and body—is damaged, often leading to lasting problems with movement, sensation, and organ control below the injury.

Introduction

For men with SCI, one of the most common and frustrating complications is urinary tract infection (UTI). This happens because bladder control is often lost, requiring catheters or other bladder management tools that make it easier for bacteria to enter. Additionally, bowel issues after SCI can lead to contact with stool, which also introduces harmful bacteria. These bacteria can remain in the bladder due to incomplete emptying, setting the stage for frequent infections. 

When these infections no longer respond to common antibiotics, they become drug-resistant UTIs. These are harder to treat and carry serious risks.

Unfortunately, even in top rehabilitation centers, UTI treatment for men with SCI is often based on a doctor's personal experience rather than proven guidelines, increasing the risk of antibiotic overuse and resistance.

Epidemiology of UTIs in SCI

Urinary tract infections (UTIs) are a frequent complication in men with spinal cord injury (SCI), with annual infection rates reaching up to 68% in some reports. This high incidence is largely due to impaired bladder function and the need for catheterization, which introduces bacteria directly into the urinary tract. According to the Model Systems Knowledge Translation Center, UTIs are among the most common secondary health conditions in SCI patients.

Drug-resistant UTIs are a growing concern in this population. In a large study analyzing 2,629 urine samples from SCI patients, 73.4% showed significant bacteriuria, and multidrug-resistant (MDR) organisms were identified in 1.1% overall. Patients with indwelling catheters had a notably higher prevalence: 3.3% with suprapubic and 2.6% with urethral catheters, compared to lower rates in those not using catheters. Resistance was more common among males and patients with tetraplegia, especially those recently hospitalized.

Other studies have reported even higher resistance rates—between 30–50%—among catheterized SCI patients, reflecting a global trend of increasing antibiotic resistance.  These figures underline the urgent need for better infection control and targeted treatment strategies to manage UTIs effectively in men with SCI.

Pathophysiology & Risk Factors

Spinal cord injury (SCI) often leads to neurogenic bladder, characterized by disrupted neural control of bladder storage and voiding. This condition results in incomplete emptying and urinary stasis, creating a favorable environment for bacterial growth and recurrent urinary tract infections (UTIs). The impaired bladder dynamics in SCI patients increase the need for catheterization, which itself is a key risk factor for infection.

Indwelling catheters (IDC), such as Foley and suprapubic catheters, are frequently associated with persistent bacterial colonization due to prolonged foreign body exposure and biofilm formation. These methods significantly elevate the risk of both UTIs and multidrug-resistant (MDR) organisms. Studies show that long-term IDC use leads to higher rates of complications, including bladder cancer and resistant infections. Intermittent catheterization (SIC), while still invasive, is associated with a lower colonization risk and better outcomes. Nevertheless, E. coli and Pseudomonas aeruginosa are common pathogens in SIC and SPC users, respectively, with geographical variations in resistance profiles.

Key risk factors in men with SCI include age-related prostate enlargement, which can further obstruct urinary flow, and autonomic dysreflexia—a dangerous increase in blood pressure triggered by bladder irritation. Men may have slightly lower UTI risk due to longer urethral anatomy, but complications can still be severe due to delayed recognition and treatment.

Increased resistance to commonly used antibiotics, such as ciprofloxacin, highlights the importance of personalized bladder management plans. Healthcare professionals should evaluate each patient’s risk profile and bladder management method to reduce UTI frequency and improve long-term outcomes.

Common Pathogens & Resistance Patterns

Urinary tract infections (UTIs) are highly prevalent in individuals with spinal cord injury (SCI), largely due to long-term catheter use and colonization by gut and perineal flora. The most common uropathogens isolated in this population include Escherichia coli (40–60%), Pseudomonas aeruginosa (10–20%), and Enterococcus species. These organisms reflect both endogenous colonization and nosocomial exposure patterns.

Resistance rates are alarmingly high in this patient group, driven by recurrent infections and frequent antimicrobial use. Extended-spectrum β-lactamase (ESBL)-producing E. coli strains represent 25–35% of isolates in many reports, limiting the efficacy of commonly used antibiotics such as cephalosporins and fluoroquinolones. Carbapenem-resistant P. aeruginosa has also emerged as a significant concern, with resistance rates reaching up to 15% in some SCI cohorts.

Multidrug-resistant (MDR) Enterobacteriaceae, particularly Klebsiella pneumoniae and E. coli, have shown a concerning upward trend over the past decade. In one study, MDR pathogens were increasingly detected over 13 years, with MRSA surpassing MRAB in 2013, indicating an escalating resistance crisis. In the same study, Klebsiella and E. coli accounted for 29% and 24% of MDR isolates, respectively, although these rates were higher than those seen in outpatient settings, emphasizing variability based on care environments.

Overall, these resistance patterns underscore the necessity for individualized antibiotic selection, guided by local antibiograms and bladder management methods. Judicious use of antibiotics and optimal voiding strategies, such as minimizing long-term use of indwelling catheters, are essential in curbing further resistance in the SCI population.

Clinical Presentation & Diagnosis

Urinary tract infections (UTIs) in males with spinal cord injury (SCI) often present atypically. Common symptoms include fever, fatigue, increased spasticity, nausea, chills, and autonomic dysreflexia—particularly in individuals with injuries at T6 or above. Dark, cloudy, foul-smelling urine with gritty sediment or mucus may also indicate infection. Diagnostically, a UTI is confirmed with a urine culture showing ≥10⁵ CFU/mL in men or ≥10² CFU/mL in catheterized specimens. 

Early recognition is critical, as symptoms may escalate quickly. Routine laboratory work-up includes urine culture and sensitivity; imaging may be needed for recurrent cases. Early warning signs like sediment or mucus in the urine should prompt increased hydration, avoidance of alcohol and caffeine, and catheter care adjustments. Antibiotics should only be initiated after proper testing and based on symptoms, as asymptomatic bacteriuria is common and does not always require treatment. Overuse can lead to antibiotic resistance, making future infections harder to treat.

Clinical Presentation & Diagnosis

Effective management of UTIs in patients with spinal cord injury (SCI) requires a multifaceted approach, combining clinical vigilance, microbiological guidance, and cautious use of antibiotics to minimize resistance.

Empiric therapy should be initiated only after urine is collected for microbiological analysis. This was unanimously supported by all surveyed SCI centers. In cases of severe symptoms or fever, empiric antibiotics were started immediately—most commonly fluoroquinolones or cotrimoxazole. Nitrofurantoin, due to its favorable resistance profile and good urinary concentrations, was the preferred oral agent in patients using various voiding methods, especially suprapubic catheterization (SPC). Trimethoprim-sulfamethoxazole also demonstrated greater efficacy than ciprofloxacin in those using self-intermittent catheterization (SIC). However, ciprofloxacin resistance was notable, especially in freely voiding individuals, and should be reserved for second-line use.

Culture-guided therapy remains essential. Once microbiology results are available (typically within 72 hours), therapy should be adjusted accordingly. Given the polymicrobial nature of infections in SCI and varying resistance profiles, tailoring antibiotics based on local antibiograms is crucial.

Non-antibiotic measures like probiotics or cranberry extract show limited evidence of benefit. Cranberry pills may be preferred over juice to avoid excess sugar, though studies suggest minimal therapeutic impact for acute UTIs in SCI patients.

Overall, the treatment should focus on symptomatic UTIs only, avoiding overtreatment of asymptomatic bacteriuria, which risks promoting resistance without clinical benefit.

Prevention & Patient Education

While urinary tract infections (UTIs) are common in spinal cord injury (SCI) patients, a proactive approach can reduce frequency and severity. Proper catheter care is essential—always use sterile technique and replace indwelling catheters regularly, typically every 4–6 weeks. Those using intermittent catheterization should ensure complete bladder emptying to prevent over-distension and stone formation, both of which increase UTI risk.

Fluid intake is another critical preventive measure. Patients should aim for 2–3 liters of water per day, unless otherwise advised by a healthcare professional. Adequate hydration supports bladder flushing, maintains healthy bowel movements, and promotes skin integrity. 

Bladder training and avoiding overfilling can further protect against infections. Recognizing early signs of UTI can prompt early intervention. When symptoms arise, increasing hydration, adjusting catheter use, or changing the catheter may help prevent progression.

Emerging preventive strategies include vaccines and novel prophylactics, such as weekly oral cycling antibiotics (WOCA), which have shown promise in reducing both UTIs and multidrug-resistant bacteria (MDRB) without increasing resistance.

Conclusion & Future Directions

Managing drug-resistant UTIs in male SCI patients remains a complex challenge due to catheter use and rising antimicrobial resistance. Misuse and overuse of antibiotics further fuel resistance, making future infections harder to treat. Choosing the right antibiotic requires urine culture and sensitivity testing—not guesswork. Antimicrobial stewardship, individualized bladder care, and alternative therapies are urgently needed. Future efforts must prioritize patient-centered education, targeted research, and innovations like QuickChange Wraps to improve outcomes and quality of life.

For those seeking support, we invite you to purchase a 10 Count Trial Pack here or request a professional-use sample pack for healthcare institutions here.

References:

1. Alshahri, S., Alghaiheb, A., Alanazi, A., Alshammari, S., & Alomair, A. (2024). Antibiogram data of urinary tract infection in spinal cord injury patients in an outpatient setting. Neurosciences Journal, 29(1), 57–62. https://doi.org/10.17712/nsj.2024.1.20230063

2. Bennett, C. J., Young, M. N., & Darrington, H. (1995). Differences in urinary tract infections in male and female spinal cord injury patients on intermittent catheterization. Paraplegia, 33(2), 69–72. https://doi.org/10.1038/sc.1995.17

3. Everaert, K., Lumen, N., Kerckhaert, W., Willaert, P., & van Driel, M. (2009). Urinary tract infections in spinal cord injury: Prevention and treatment guidelines. Acta Clinica Belgica, 64(4), 335–340. https://doi.org/10.1179/acb.2009.052

4. Kang, M.-S., Lee, B.-S., Lee, H.-J., Hwang, S.-W., & Han, Z.-A. (2015). Prevalence of and risk factors for multidrug-resistant bacteria in urine cultures of spinal cord injury patients. Annals of Rehabilitation Medicine, 39(5), 686–695. https://doi.org/10.5535/arm.2015.39.5.686

5. National Institute of Neurological Disorders and Stroke. (2025, April). Spinal cord injury. National Institutes of Health. https://www.ninds.nih.gov/health-information/disorders/spinal-cord-injury

6. Pannek, J. (2011). Treatment of urinary tract infection in persons with spinal cord injury: Guidelines, evidence, and clinical practice. A questionnaire-based survey and review of the literature. Journal of Spinal Cord Medicine, 34(1), 11–15. https://doi.org/10.1179/107902610X12886261091839

7. Poirier, C., Dinh, A., Salomon, J., Grall, N., Andremont, A., & Bernard, L. (2016). Prevention of urinary tract infections by antibiotic cycling in spinal cord injury patients and low emergence of multidrug resistant bacteria. Médecine et Maladies Infectieuses, 46(6), 294–299. https://doi.org/10.1016/j.medmal.2016.04.001

8. Waites, K. B., Chen, Y., DeVivo, M. J., Canupp, K. C., & Moser, S. A. (2000). Antimicrobial resistance in gram-negative bacteria isolated from the urinary tract in community-residing persons with spinal cord injury. Archives of Physical Medicine and Rehabilitation, 81(6), 764–769. https://doi.org/10.1016/s0003-9993(00)90108-4