Dr Vivien Li, Neurology SpR
National Hospital for Neurology & Neurosurgery
MS Foundation MasterClass 7, 2019
An estimated 50-80% of people with MS (PwMS) develop urogenital dysfunction and urinary tract infections (UTIs) are one of the commonest reasons for emergency attendances and hospital admissions. UTIs have a major impact on morbidity and quality of life, increase mortality risk and add considerable cost to the health system. From 2016-2017, health episode statistics (HES) data collected by the University College London Partners (UCLP) MS Service Group, with sources include UCLH NHS Foundation Trust, Royal Free London NHS Trust, Bart’s Healthcare NHS Trust and other hospitals and clinical commissioning groups (CCGs) across the regional NHS community services, found that amongst non-elective admissions where MS is secondary diagnosis, costs for UTIs were by far the highest of all conditions, totalling almost £1 million1.
The aims of this project were to:
- Identify PwMS with unplanned UTI presentations using health episode statistics data;
- Characterise features of these patients’ MS and UTI presentations;
- Identify patient-specific and systemic areas of management that can be improved to reduce UTI frequency using existing guidelines2,3;
- Implement these strategies in a multidisciplinary outpatient clinic;
- Reassess frequency of non-elective UTI presentations after optimisation of management in these patients.
HES data were audited to identify PwMS with emergency department (ED) presentations and admissions for UTI to University College London Hospitals NHS Trust as the primary diagnosis (code N390) and MS as the secondary diagnosis over 5 years (April 1, 2014-March 31, 2019). Patient records were reviewed for data including demographics, MS history (subtype, duration, EDSS), urological symptoms and interventions and admission(s) for UTI (duration, frequency, microbiology, treatment). Patients, their carers and GPs were contacted directly if there was additional missing information.
Over the audited time period, 52 PwMS (25 female, 27 male) with mean age of 59 years (range 27-84) had non-elective UTI presentations. 6 met the European Association of Urology criteria for recurrent UTIs (i.e. ≥3 in last 12 months or ≥2 in last 6 months) and 16 had multiple presentations not meeting above criteria. 30 had single presentations. The most common MS subtype overall was secondary progressive MS (25 patients, 48%), mean duration of MS was 22 years and median EDSS was 8.5 (range 4-10). Compared to those with only a single presentation, PwMS with multiple presentations were significantly older (mean age 65 vs. 55), were less likely to have relapsing remitting MS (1 patient [5%] vs. 13 patients [37%]) and therefore also less likely to be on MS disease-modifying therapy (1 patient [5%] vs. 10 patients [33%]).
33 (63%) patients were using a catheter (18 suprapubic catheter [SPC], 9 permanent urethral indwelling catheter [IDC], 6 intermittent self-catheterisation [ISC]) and 4 were using condom drainage. Those with multiple UTI presentations were more likely to have an IDC (7 patients [32%] vs. 2 patients [7%]) compared to those with single presentations, of whom 13 patients (43%) did not require a catheter, compared to only 2 patients (9%) amongst those with multiple presentations. Of the 13 patients who had urodynamic studies on record, detrusor overactivity was the most common finding (in 12 [92%]) and 7 also had evidence of voiding dysfunction. 10 patients had received intradetrusor botulinum toxin and 30 were on pharmacological therapy for overactive bladder symptoms. 22 patients (42%) were taking a form of UTI prophylaxis (12 antibiotics, 5 D-mannose, 3 methenamine, 3 cranberry). 7 (13%) patients had a history of renal stones.
Of the 33 patients using a catheter, 17 (52%) had undergone cystoscopy in the prior 5 years. Only 11 patients (21%) had renal tract imaging within the prior 12 months. Only 21 (40%) were under current urology/uro-neurology and 20 (38%) under MS/neurology follow-up, although a small number had declined appointments due to poor mobility.
In total there were 95 ED presentations (range 1-8 per patient) and 87 hospital admissions (range 1-7 per patient). Mean length of stay per admission was 9.1 days (range 0-108 [latter complicated by Clostridium difficile infection]). Results of available urine cultures showed mixed growth in 27, Escherichia coli in 12, Pseudomonas aeruginosa in 9, Klebsiella spp. in 5, Enterococcus spp. in 1, methicillin resistant Staphylococcus aureus in 1 and Candida spp. in 1. 14 were unknown and 16 had no growth. 39 episodes required treatment with intravenous antibiotics and mean duration of antibiotic treatment was 6.84 days (range 3-28 [prostatitis]).
Based on published guidelines, key recommendations applicable to this cohort include:
- Measurement of post-void residual volume and catheterisation (ideally by ISC) if consistently >100ml;
- Optimisation of catheter type (i.e. changing from IDC to ISC or SPC, use of a catheter valve as opposed to continuous drainage into a leg bag);
- Adequate treatment of lower urinary tract symptoms;
- Periodic review by trained health care professional;
- In patients with recurrent UTIs, cystoscopy and ultrasound should be performed to exclude underlying abnormalities such as bladder stones;
- Use of appropriate prophylactic agent if no alternative causes of recurrent UTIs are identified or significant complications from UTI.
As the next step, the 8 PwMS accounting for the highest numbers of encounters (41% of ED presentations, 38% of admissions) are being brought to a multidisciplinary clinic with MS, urology and specialist nurse input to assess current management and identify areas that can be optimised. For example those without recent imaging or cystoscopies will undergo these investigations and review of management of lower urinary tract symptoms and appropriateness of UTI prophylaxis will be performed. Future frequency of UTIs will be assessed to compare with that prior to the intervention. In addition, an ongoing plan will be to produce a checklist of management strategies that can be applied for all PwMS with unplanned UTI presentations.
- Porter B et al. Urinary tract infection in multiple sclerosis: closing an audit loop by co-design and innovation. British Journal of Neuroscience Nursing 2019 15:1, 20-27.
- Fowler CJ et al. A UK consensus on the management of the bladder in multiple sclerosis. J Neurol Neurosurg Psychiatry 2009; 80:470-477.
- National Institute for Health Care and Excellence (NICE). Clinical Guideline 148: Urinary incontinence in neurological disease. Management of lower urinary tract dysfunction in neurological disease. http://guidance.nice.org.uk/cg148. 2012.