Highlights
- •High dose steroids to treat acute MS relapses may be delayed when UTI is suspected.
- •Accurate urine screening allows early treatment and reduces unnecessary antibiotics.
- •≥2/3 of positive nitrites, leukocyte esterase and cloudy urine gives 87% accuracy.
- •Risks of high dose steroids when bacteriuria is present remains to be established.
Abstract
Introduction
To evaluate an updated algorithm in the detection of urinary tract infection (UTI)
prior to high-dose corticosteroid treatment in acute relapses in multiple sclerosis
(MS). This updated algorithm aimed to decrease the unnecessary use of antibiotics,
whilst maintaining accuracy and safety.
Methods
Prospective cohort study of 471 consecutive patients with MS relapses in a hospital-based
outpatient acute relapse clinic. 172 patients met exclusion criteria, leaving 299
patients for analysis. Patients underwent urine dipstick and were treated for UTI
if 2 or more of: nitrites, leukocyte esterase and cloudy urine were positive. Patients
with confirmed acute MS relapse were treated with high dose intravenous or oral methylprednisolone.
Results
Significant bacteriuria (>105 colony forming units/mL) was present in 33 (11%, 95% CI 8-15) patients. The algorithm
sensitivity and specificity was 24% and 94% respectively; the negative predictive
value was 91%. The overall accuracy of the algorithm was 87%. No adverse sequelae
were identified in 25 patients who received high dose methylprednisolone in the presence
of an untreated UTI.
Conclusion
With an improved specificity, this updated algorithm addresses previous issues concerning
the unnecessary prescription of antibiotics, whilst improving accuracy and maintaining
safety.
Keywords
Abbreviations:
HDC (High-dose corticosteroids), IV (intravenous), MS (multiple sclerosis), UTIs (urinary tract infections), LE (leucocyte esterase), NPV (negative predictive value), PPV (positive predictive value), MSU (mid-stream urine), SD (standard deviation), CI (confidence interval), PwMS (people with multiple sclerosis)To read this article in full you will need to make a payment
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References
- Corticosteroids or ACTH for acute exacerbations in multiple sclerosis (Review).Cochrane Database Syst. Rev. 2009; : 1-3
- Bladder dysfunction in multiple sclerosis: a 6-year follow-up study.Acta Neurol. Belg. 2017; 117: 83-90
- Treating asymptomatic bacteriuria before immunosuppressive therapy during multiple sclerosis: should we do it?.in: Multiple Sclerosis and Related Disorders. 18. 2017: 161-163
- Prospective study on the relationship between infections and multiple sclerosis exacerbations.Brain. 2002; 125: 952-960
- Neurological symptoms accompanying urinary tract infections.Eur. Neurol. 2010; 63: 180-183
- The risk of relapses in multiple sclerosis during systemic infections.Neurology. 2006; 67: 652-659
- Urinary tract infections in multiple sclerosis.Mult. Scler. J. 2016; 22: 855-861
- Fatal acute pyelonephritis following pulsed methylprednisolone for rheumatoid arthritis.Ann. Rheum. Dis. 1990; 49: 955-956
- Association between urinary symptoms and urinary tract infection in patients with multiple sclerosis.Global J. Health Sci. 2015; 8: 253
- Urinary tract infections in multiple sclerosis: under-diagnosed and under-treated? A clinical audit at a large University Hospital.Am. J. Clin. Exp. Immunol. 2014; 3: 57-67
- Discrediting microscopic pyuria and leucocyte esterase as diagnostic surrogates for infection in patients with lower urinary tract symptoms: results from a clinical and laboratory evaluation.BJU Int. 2013; 112: 231-238
- Comparison of test characteristics of urine dipstick and urinalysis at various test cutoff points.Ann. Emerg. Med. 2001; 38: 505-512
- Screening tests for urinary tract infection in children: a meta-analysis.Pediatrics. 1999; 104: e54
- Testing for urinary tract colonization before high-dose corticosteroid treatment in acute multiple sclerosis relapses: prospective algorithm validation.Eur. J. Neurol. 2013; 20: 448-452
- Validity, accuracy, and predictive value of urinary tract infection signs and symptoms in individuals with spinal cord injury on intermittent catheterization.J. Spinal Cord Med. 2009; 32: 568-573
- Health Episode Statistics in Multiple Sclerosis.2018
- Oral and intravenous steroids for multiple sclerosis relapse: a systematic review and meta-analysis.J. Neurol. 2017; 264: 1697-1704
- Treatment of multi-resistant urinary tract infections in patients with multiple sclerosis.Pharmaceutisch Weekblad. 1987; 9 (Scientific Edition): S76-S77
- The prevalence, etiologic agents and risk factors for urinary tract infection among spinal cord injury patients.Jundishapur J. Microbiol. 2014; 7: 1-8
- Laboratory evaluation of leukocyte esterase and nitrite tests for the detection of bacteriuria.J. Clin. Microbiol. 1985; 21: 840-842
- Gram-positive uropathogens, polymicrobial urinary tract infection, and the emerging microbiota of the urinary tract.Microbiol. Spectr. 2016; 4: 1-54
- Voided midstream urine culture and acute cystitis in premenopausal women.N. Engl. J. Med. 2013; 369: 1883-1891
- Traiter ou ne pas traiter les bactériuries asymptomatiques avant bolus de méthylprednisolone ?.Rev. Neurol. 2015; 171: 669-673
Article info
Publication history
Published online: September 16, 2019
Accepted:
September 9,
2019
Received in revised form:
August 30,
2019
Received:
June 21,
2019
Identification
Copyright
© 2019 Elsevier B.V. All rights reserved.
