Screening for urinary tract colonisation prior to corticosteroid administration in acute multiple sclerosis relapses: Validation of an updated algorithm

Published:September 16, 2019DOI:https://doi.org/10.1016/j.jns.2019.116456

      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)
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      References

        • Filippini G.
        • Brusaferri F.
        • Wa S.
        • Citterio A.
        • Ciucci G.
        • Midgard R.
        • et al.
        Corticosteroids or ACTH for acute exacerbations in multiple sclerosis (Review).
        Cochrane Database Syst. Rev. 2009; : 1-3
        • Kisic Tepavcevic D.
        • Pekmezovic T.
        • Dujmovic Basuroski I.
        • Mesaros S.
        • Drulovic J.
        Bladder dysfunction in multiple sclerosis: a 6-year follow-up study.
        Acta Neurol. Belg. 2017; 117: 83-90
        • Rouzaud C.
        • Hautecoeur P.
        • Donze C.
        • Heinzlef O.
        • Dinh A.
        • Creange A.
        • et al.
        Treating asymptomatic bacteriuria before immunosuppressive therapy during multiple sclerosis: should we do it?.
        in: Multiple Sclerosis and Related Disorders. 18. 2017: 161-163
        • Buljevac D.
        • Flach H.Z.
        • Hop W.C.J.
        • Hijdra D.
        • Laman J.D.
        • Savelkoul H.F.J.
        • et al.
        Prospective study on the relationship between infections and multiple sclerosis exacerbations.
        Brain. 2002; 125: 952-960
        • Hufschmidt A.
        • Shabarin V.
        • Rauer S.
        • Zimmer T.
        Neurological symptoms accompanying urinary tract infections.
        Eur. Neurol. 2010; 63: 180-183
        • Correale J.
        • Fiol M.
        • Gilmore W.
        The risk of relapses in multiple sclerosis during systemic infections.
        Neurology. 2006; 67: 652-659
        • Phé V.
        • Pakzad M.
        • Curtis C.
        • Porter B.
        • Haslam C.
        • Chataway J.
        • et al.
        Urinary tract infections in multiple sclerosis.
        Mult. Scler. J. 2016; 22: 855-861
        • Walsh D.A.
        • Durance R.A.
        Fatal acute pyelonephritis following pulsed methylprednisolone for rheumatoid arthritis.
        Ann. Rheum. Dis. 1990; 49: 955-956
        • Nikseresht A.
        • Salehi H.
        • Foroughi A.A.
        • Nazeri M.
        Association between urinary symptoms and urinary tract infection in patients with multiple sclerosis.
        Global J. Health Sci. 2015; 8: 253
        • Mahadeva A.
        • Tanasescu R.
        • Gran B.
        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
        • Kupelian A.S.
        • Horsley H.
        • Khasriya R.
        • Amussah R.T.
        • Badiani R.
        • Courtney A.M.
        • et al.
        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
        • Lammers R.L.
        • Gibson S.
        • Kovacs D.
        • Sears W.
        • Strachan G.
        Comparison of test characteristics of urine dipstick and urinalysis at various test cutoff points.
        Ann. Emerg. Med. 2001; 38: 505-512
        • Gorelick M.H.
        • Shaw K.N.
        Screening tests for urinary tract infection in children: a meta-analysis.
        Pediatrics. 1999; 104: e54
        • Rakusa M.
        • Murphy O.
        • McIntyre L.
        • Porter B.
        • Panicker J.
        • Fowler C.
        • et al.
        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
        • Massa L.M.
        • Hoffman J.M.
        • Cardenas D.D.
        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 IQ Limited
        Health Episode Statistics in Multiple Sclerosis.
        2018
        • Lattanzi S.
        • Cagnetti C.
        • Danni M.
        • Provinciali L.
        • Silvestrini M.
        Oral and intravenous steroids for multiple sclerosis relapse: a systematic review and meta-analysis.
        J. Neurol. 2017; 264: 1697-1704
        • van Poppel H.
        • Baert L.
        Treatment of multi-resistant urinary tract infections in patients with multiple sclerosis.
        Pharmaceutisch Weekblad. 1987; 9 (Scientific Edition): S76-S77
        • Togan T.
        • Kurt Azap O.
        • Durukan E.
        • Arslan H.
        The prevalence, etiologic agents and risk factors for urinary tract infection among spinal cord injury patients.
        Jundishapur J. Microbiol. 2014; 7: 1-8
        • Pfaller M.A.
        • Koontz F.P.
        Laboratory evaluation of leukocyte esterase and nitrite tests for the detection of bacteriuria.
        J. Clin. Microbiol. 1985; 21: 840-842
        • Lewis A.L.
        • Kline K.A.
        Gram-positive uropathogens, polymicrobial urinary tract infection, and the emerging microbiota of the urinary tract.
        Microbiol. Spectr. 2016; 4: 1-54
        • Hooton T.M.
        • Roberts P.L.
        • Cox M.E.
        • Stapleton A.E.
        Voided midstream urine culture and acute cystitis in premenopausal women.
        N. Engl. J. Med. 2013; 369: 1883-1891
        • Donzé C.
        • Dinh A.
        • Heinzlef O.
        • Hautecoeur P.
        Traiter ou ne pas traiter les bactériuries asymptomatiques avant bolus de méthylprednisolone ?.
        Rev. Neurol. 2015; 171: 669-673